Form 23-Ep - Application For Enrollment To Practice Before The Internal Revenue Service As An Enrolled Retirement Plan Agent (Erpa)

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23-EP
Application for Enrollment to Practice Before the Internal
Form
Revenue Service as an Enrolled Retirement Plan Agent
OMB No. 1545-0950
(Rev. December 2014)
(ERPA)
Department of the Treasury
See Instructions on Page 3
Internal Revenue Service
Important things you need to know and do before you file this form:
• Take and pass the Enrolled Retirement Plan Agent Special Enrollment Examination
For IRS use:
• Read Circular 230
• The application fee is $30.
Date Enrolled:
Visit to file and pay electronically. This fee is non-refundable.
Check here if you are a former Internal Revenue Service Employee, and enter the date you separated
from the Service
.
/
/
Enrollment Number:
Part 1. Tell Us About Yourself
1
Your Social Security Number
If you do not have an SSN, please check this box.
2
Date of Birth
mm/dd/yyyy
3
Your Full Legal Name
Last
First
MI
4
Current Address
Number
Street
Suite or Apt. Number
City
State
Zip Code
Country
Your email Address:
Your Contact Telephone Number:
5
Enter your PTIN number issued by the IRS or Candidate Number assigned by the
American Institute of Retirement Education (AIRE).
6
Do you have an Employer Identification Number (EIN)?
Yes
No
If Yes, enter all EINs, business names, and addresses below (attach additional pages, if necessary):
EIN
Business Name
Business Address
23-EP
For Privacy Act and Paperwork Reduction Act Notice, see page 3.
Form
(Rev. 12-2014)
Cat. No. 51483V

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