Form W-12 - Irs Paid Preparer Tax Identification Number (Ptin) Application And Renewal Page 2
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Form W-12 (Rev. 10-2014)
Page
8 Federal Tax
Are you current on both your individual and business federal taxes, including any corporate and employment
Compliance
tax obligations?
Yes
No
If you have never filed a U.S. individual income tax return because you are not required to do so, check the
“Yes” box.
If “No,” provide an explanation.
9 Professional
Check all that apply. Enter state abbreviation and appropriate number(s):
Credentials
Number(s):
Expiration Date(s):
Attorney - Licensed in which state(s):
Certified Public Accountant (CPA) -
Licensed in which state(s):
Number(s):
Expiration Date(s):
Number(s):
Expiration Date(s):
Enrolled Agent (EA)
Number(s):
Expiration Date(s):
Enrolled Actuary
Number(s):
Expiration Date(s):
Enrolled Retirement Plan Agent (ERPA)
State Regulated Tax Preparer-State(s):
Number(s):
Expiration Date(s):
Certified Acceptance Agent Number
None
Skip line 10 if you are an attorney, CPA, or EA.
10 Form 1040
Do you prepare Form 1040 series tax returns (or accompanying schedules) for compensation? (If you ONLY
Preparation
prepare Form 1040-PR or Form 1040-SS for residents of Puerto Rico, check “No.”)
Yes
No
11 Business Name
Yes
No
Are you self-employed or an owner, partner, or officer of a tax preparation business?
and
If you check “Yes,” complete this line. If you check “No,” go to line 12.
Identification
Enter the business name
Numbers
Your CAF Number
EIN
EFIN
-
If this is your initial application for a PTIN, continue to line 12. If you are renewing your PTIN, go to line 14.
Enter the address used on your last U.S. individual income tax return you filed.
12 Address of
Your
Last U.S.
Individual
If you have never filed a U.S. federal income tax return or do not have a U.S. federal income tax filing
Income Tax
requirement, check here
. See line 12 instructions for documents that must be submitted with this form and
Return Filed
continue to line 14.
W-12
Form
(Rev. 10-2014)
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