IRS Paid Preparer Tax Identification Number (PTIN)
Application and Renewal
OMB No. 1545-2190
(Rev. October 2014)
Department of the Treasury
Information about Form W-12 and its separate instructions is available at
Internal Revenue Service
1 Name and PTIN
(Print in ink or
(Enter PTIN: P
If you checked the Initial application box and are applying for a PTIN between Oct. 1 and Dec. 31, indicate
2 Year of
below whether you want your PTIN to be valid for the current calendar year or the next calendar year.
Current calendar year
Next calendar year
If you checked the Renewal application box and also need to renew for a previous calendar year, indicate the
year below and see the line 2 instructions for additional guidance.
3 SSN and Date
Date of birth (month, day, year)
Street address. Use a P.O. box number only if the post office does not deliver mail to your street address.
City or town, state/province, and, if outside U.S., country. Include ZIP or postal code where appropriate. Do
not abbreviate name of country.
Phone Number (
Business address (if different than line 4 information above)
Business city or town, state/province, and, if outside U.S., country. Include ZIP or postal code where
appropriate. Do not abbreviate name of country.
Domestic business phone number
International business phone number
5b Business Name
Enter the business name and website address (optional).
6 Email Address Enter the email address that should be used to contact you.
7 Past Felony
Have you been convicted of a felony in the past 10 years?
If “Yes,” list the date and the type of felony conviction(s).
For Privacy Act and Paperwork Reduction Act Notice, see instructions.
Cat. No. 55469F