Fillable Printable Form W-12
Fillable Printable Form W-12
Form W-12
Form W-12
(Rev. June 2017)
Department of the Treasury
Internal Revenue Service
IRS Paid Preparer Tax Identification Number (PTIN)
Application and Renewal
▶
Go to www.irs.gov/FormW12 for instructions and the latest information.
OMB No. 1545-2190
1Name and PTIN
(Print in ink or
Type)
First name Middle nameLast name
Initial applicationRenewal application
(Enter PTIN: P)
2Year of
Application/
Renewal
If you checked the “Initial application” box and are submitting this form between October 1 and December 31,
indicate 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(s), indicate
the year(s) below and see the line 2 instructions for additional guidance.
Prior year(s) (YYYY):,,
3SSN and Date
of Birth
SSN
--
Date of birth (MM/DD/YYYY)
//
4Personal
Mailing
Address and
Phone Number
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 or province, country, and ZIP or foreign postal code. Do not abbreviate name of country.
Phone Number( )-
5aBusiness
Mailing
Address and
Phone Number
Business address (if different than line 4 information above)
City or town, state or province, country, and ZIP or foreign postal code. Do not abbreviate name of country.
Domestic business phone number
( )
-EXT.
International business phone number
+
bBusiness
Identification
Are you self-employed or an owner, partner, or officer of a tax return preparation business?YesNo
If “Yes,” then complete this line. If “No,” go to line 6.
Enter the business name.
Your CAF Number
EIN
-
EFIN
Website address (optional)
6Email AddressEnter the email address that should be used to contact you.
For Privacy Act and Paperwork Reduction Act Notice, see instructions.
Cat. No. 55469F
Form W-12 (Rev. 6-2017)
Form W-12 (Rev. 6-2017)
Page 2
7Past Felony
Convictions
Have you been convicted of a felony in the past 10 years?
YesNo
If “Yes,” list the date and the type of felony conviction(s).
If this is your initial application for a PTIN, continue to line 8a. If you are renewing your PTIN, go to line 11.
8 Never Filed a U.S. Federal Income Tax Return
Address of
Your
Last U.S.
Individual
Income Tax
Return Filed
a If you have never filed a U.S. federal income tax return or do not have a U.S. federal income tax filing
requirement, check here
. See line 8 instructions for documents that must be submitted with this form and
continue to line 11.
b Enter the address used on your last U.S. individual income tax return you filed.
9Filing Status
and Tax Year
on Last U.S.
Individual
Income Tax
Return Filed
Single
Married filing jointly
Married filing separately
Head of Household
Qualifying widow(er) with dependent child
Tax Year (YYYY)
Note: If your last return was filed more than 4 years ago, see instructions.
Reserved
10ReservedReserved
11Federal Tax
Compliance
Are you current on both your individual and business federal taxes, including any corporate and employment
tax obligations? Note: If you have never filed a U.S. individual income tax return because you are not required
to do so, check the “Yes” box.
YesNo
If “No,” provide an explanation.
www.irs.gov/w12
Form W-12 (Rev. 6-2017)
Form W-12 (Rev. 6-2017)
Page 3
12Professional
Credentials
Check all that apply. Note: DO NOT check any professional credentials that are currently expired or
retired. Enter state abbreviation and appropriate number(s). If the expiration date is left blank or incomplete,
then NO professional credential will be added when the application is processed.
Attorney—Licensed in which
jurisdiction(s):
Number(s):Expiration Date(s):
Certified Public Accountant (CPA)—
Licensed in which jurisdiction(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)
Number(s):Expiration Date(s):
State Regulated Tax Return Preparer
—Licensed in which jurisdiction(s):
Number(s):Expiration Date(s):
Certifying Acceptance Agent (CAA)
Number:
None
13ReservedReserved
Sign
Here
Under penalties of perjury, I declare that I have examined this application and to the best of my knowledge and belief, it
is true, correct, and complete. I understand any false or misleading information may result in criminal penalties and/or
the denial or termination of a PTIN.
▲
Your signatureDate (MM/DD/YYYY)
//
How To File
Online. Go to the webpage www.irs.gov/ptin for information. Follow the instructions to submit Form W-12. If you submit your
application online, your PTIN generally will be provided to you immediately after you complete the application.
By mail. Complete Form W-12. Send the form to:
IRS Tax Professional PTIN
Processing Center
1605 George Dieter PMB 678
El Paso, TX 79936
Note: Allow 4 to 6 weeks for processing of paper Forms W-12. For additional information, refer to the separate Instructions for
Form W-12.
For Internal Use Only
www.irs.gov/w12
Form W-12 (Rev. 6-2017)
