Form 8945 - Ptin Supplemental Application For U.s. Citizens Without A Social Security Number Due To Conscientious Religious Objection

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8945
PTIN Supplemental Application For U.S. Citizens
Form
Without a Social Security Number Due To
OMB No. 1545-2188
(September 2010)
Conscientious Religious Objection
Department of the Treasury
Internal Revenue Service
Do not submit this form if you have a U.S. Social Security Number (SSN).
Part I
To Be Completed by Preparer
1
First name
Middle name
Last name
Name
2
Street address, apt. number, or rural route number. If you have a P.O. box, see instructions.
Applicant’s
Complete
City or town, state, and ZIP code
Mailing Address
Birth
3
Date of birth (mm/dd/yyyy)
Country of birth
4
Male
Information
Female
Name at birth (if different from above)
First name
Middle name
Last name
5
Citizenship and identification document(s) submitted (see instructions)
Citizenship
Passport/Passport Card
U.S. Driver’s License
U.S. State ID Card
and
Voter's Registration Card
U.S. Military ID Card
Foreign Military ID Card
Identification
Information
Civil Birth Certificate
Naturalization Papers
I certify that I am and continuously have been a member of
(Name of religious group)
since
(Religious district or congregation, and county and/or city, state, and ZIP code)
(Month)
(Day)
(Year)
and as a follower of the established teachings of the group, I am conscientiously opposed to applying for and receiving a social
security number. Furthermore, I state that an application for a social security number was never filed by me or on my behalf, and that I
have never received a social security number. Under penalties of perjury, I declare that I have examined this application, including
accompanying documentation and statements, and to the best of my knowledge and belief, it is true, correct, and complete.
Signature of Applicant
Date
Part II
To Be Completed by Authorized Representative of Religious Group
I certify that
is a member of
(Name of preparer)
(Name of religious group/district/congregation)
and as a dutiful follower of aforementioned religious group, has a religious objection to applying for and receiving a social security
number.
Name of Authorized Representative (print or type)
Address
Signature of Authorized
Representative
Title
Date
For IRS Use Only
8945
For Privacy Act and Paperwork Reduction Act Notice, see instructions.
Form
(9-2010)
Cat. No. 37763W

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