Publication 1635 - Understanding Your Employer Identification Numbers Page 22
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32Name and Title: Print the name and title of the fiduciary.
Telephone Number: Enter the telephone number where we can reach you if we have questions
about your application.
Signature: The fiduciary must sign.
NOTE: If an estate is used to create a trust, the trust is considered a different entity type and a new
EIN is needed.
7. Plan Administrators
Line 1
Always enter the name of the plan administrator. If the plan administrator
already has an EIN they should use that number.
Line 2
Enter the name of the plan administrator only if different from line 1.
Line 3
N/A
Line 4a
Enter your mailing address.
Line 4b
Enter your city, state, and zip code.
Lines 5a
and 5b Enter only if different from the mailing address.
Line 6
Enter the county and state where the employee plan is located.
Line 7a
N/A
Line 7b
N/A
Line 8a
Check “Plan Administrator”. If the plan administrator is an individual, enter the plan
administrator’s SSN in the space provided.
Line 8b
N/A
Line 9
Check “Created a pension plan”. Enter the type of plan created.
Line 10
Enter the starting date of the plan.
Line 11
Enter the last month of your accounting year or tax year.
Line 12
Enter the date the plan began or will begin to pay wages to employees. If you have
no employees, enter N/A.
Line 13
Enter the highest number of employees you plan to hire over the next 12 months. If
none, enter 0.
Line 14
Check the “Other” box and enter the exact type of plan that the applicant plans to
operate.
Line 15
Describe the services that will be provided.
Line 16a: Check “Yes” or “No” to whether or not you have applied for an EIN.
If “Yes”, complete lines 16b and 16c.
If “No”, skip 16b and 16c.
Line 16b If you checked “Yes” on 16a enter applicant’s legal name and trade name shown on
prior application if different from line 1 or 2 of Form SS-4.
Line 16c
If you checked “Yes” on Line 16a, give the approximate date when the application
was filed and city and state where it was filed. Enter previous EIN if known.
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Application For Clinic/group/institution/location To File Claims Or To Change Employer Identification Number (ein) Form
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Form W-13 - Exstars Reporting Information Request For Employer Identification Number And Certification
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Parent category: Financial