Form 14392 - Continuing Education Waiver Request
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1
2Department of the Treasury - Internal Revenue Service
14392
Form
OMB number
Continuing Education Waiver Request
1545-1726
(September 2012)
Applicant Name and Contact Information
Date of application (mm/dd/yyyy)
Applicant name
Telephone number
Designation
Enrolled Agent (EA)
Enrolled Retirement Plan Agent (ERPA)
Preparer Tax Identification Number (PTIN)
EA enrollment number
ERPA enrollment number
P
-EA
-EP
Requesting waiver for
Requesting waiver for
All hours
Partial hours
All hours
Partial hours
Mailing address (street, room number, apt., suite number, or P.O. Box)
City
State
ZIP code
Foreign province (or state)
Foreign country
Foreign postal code
Reasons for Requesting a Waiver During Current Renewal Cycle
Health reasons (attach medical certificate)
Extended active military duty (attach military orders)
Absence from the United States for an extended period of time due to employment or other reasons (attach letter from employer)
Other compelling reasons (attach documentation, if applicable)
Previously applied for a waiver
Date previous waiver requested (mm/dd/yyyy) Was previous waiver approved/denied
Yes
No
Approved
Denied
Mail completed form to: Office of Enrollment, P.O. Box 33968, Detroit, MI 48232
Under penalty of perjury, I declare that I have read all accompanying information and to the best of my knowledge and belief, the
information provided is true, correct and complete.
Signature
Name (printed/typed)
Date signed (mm/dd/yyyy)
IRS USE ONLY
Request for waiver
Approved
Denied
Approving Official signature
Approving Official name (printed/typed)
Date signed (mm/dd/yyyy)
14392
Form
(9-2012)
Catalog Number 59537K
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