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                                                    Application for Exemption From Social Security and 
                                                                                                                                                                          OMB No. 1545-0064 
(Rev.Form November40292018)                                     Medicare▶ Go to www.irs.gov/Form4029Taxes and Waiverfor the latestofinformation.Benefits
                                                      ▶
Department of the Treasury                               Before you file this form, see the instructions under Who may apply on page 2. 
                                                                                                                                                                          File Three Copies
Internal Revenue Service                            ▶ This exemption is granted only if the IRS returns a copy to you marked “Approved.”
Caution: Approval of Form 4029 exempts you from social security and Medicare taxes only. The exemption does not apply to federal income tax. 
Ministers, members of religious orders, and Christian Science practitioners, see Form 4361, Application for Exemption From Self-Employment Tax for 
Use by Ministers, Members of Religious Orders, and Christian Science Practitioners. 
Part I                        To Be Completed by Applicant
                            1   Name of taxpayer                                                                                                        2   Social security number 

                              Address (number, street, or P.O. box)                                                                                     3   Date of birth 

              Print or type   City or town, state, and ZIP code                                                                                         4   Contact phone number (optional)

                            5 Do not send me my Social Security Statement. 

I certify that I am and continuously have been a member of 
                                                                                                                            (Name of religious group) 

                                                                (Religious district or congregation, and county and/or city, state, and ZIP code) 
since                                                                      , and as a follower of the established teachings of that group, I am conscientiously opposed to 
                              (Month)            (Day)              (Year) 
accepting benefits of any private or public insurance that makes payments in the event of death, disability, old age, or retirement; or makes payments for the 
cost of medical care; or provides services for medical care. Public insurance includes any insurance system established by the Social Security Act. 
I request that I be exempted from paying social security and Medicare taxes on my earnings from self-employment under Internal Revenue Code section 1401 
and from the employer’s share of social security and Medicare taxes under Internal Revenue Code section 3111. 
I further request exemption from the employee’s share of social security and Medicare taxes under Internal Revenue Code section 3101, for my services as an 
employee whenever I am employed by an employer who has an identical exemption from social security and Medicare taxes. 
I waive all rights to any social security payment or benefit under Titles II and XVIII of the Social Security Act. I understand and agree that no benefits or other 
payments of any kind under Titles II and XVIII of the Social Security Act will be paid based on my wages and self-employment income to any other person. I certify that I 
have never received benefits or payments under the above titles, nor has anyone else received these benefits based on my earnings. 
I agree to notify the Internal Revenue Service within 60 days of any occurrence that results in my no longer being a member of the religious group described  
above, or no longer following the established teachings of this group. See Where to file on page 2. 
Furthermore, I understand that if the tax exemption for myself or for my employer under sections 1402(g)(1) or 3127 of the Internal Revenue Code is no longer 
effective, this waiver will also no longer be effective for: 
• Myself, with respect to all my wages and self-employment income; and 
• My employees with respect to wages I may pay to them; and that if my employer’s exemption is no longer in effect, my exemption will end with respect to 
wages paid to me by my employer. However, the waiver will no longer be effective only to the extent that benefits and other payments under Titles II and XVIII of 
the Social Security Act can be payable on the basis of: 
• My self-employment income for and after the first tax year in which the exemption ends; and 
• My wages for and after the calendar quarter following the calendar quarter in which the exemption no longer meets the requirements of section 1402(g)(1) or 
3127 on which the end of the exemption is based. 
Under penalties of perjury, I declare that I have examined this application and waiver, and to the best of my knowledge and belief, it is true and correct. 
Signature of Applicant ▶                                                                                                                                    Date ▶
Part II                       To Be Completed by Authorized Representative of Religious Group (Print or type) 

I certify that                                                                  is a member of                                                                                              . 
                                                 (Name of taxpayer)                                                         (Name of religious group/district/congregation) 

Name of Authorized Representative 
Signature of                                                               (Please print or type)                                                           (Address)
Authorized Representative ▶                                                                                   Title ▶                                       Date ▶
                                                                    Social Security Administration Use Only 
                            This religious group is recognized as being in existence continuously since December 31, 1950, as providing a reasonable level of living for 
                            its dependent members, and as being conscientiously opposed to public or private insurance. 
                            This religious group is not recognized as being in existence continuously since December 31, 1950, as providing a reasonable level of living 
                            for its dependent members, and/or as being conscientiously opposed to public or private insurance. 
Signature of 
Authorized SSA Representative ▶                                                                                                     Date  ▶
                                                                           Internal Revenue Service Use Only 
                            Approved for exemption from social security and Medicare taxes. (See Caution before Part I above.) 
                            Disapproved for exemption from social security and Medicare taxes. 
Signature and Title of  
Authorized IRS Representative ▶                                                                                                     Date ▶
For Privacy Act and Paperwork Reduction Act Notice, see page 2.                                                             Cat. No. 41277T                          Form 4029 (Rev. 11-2018)

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Form 4029 (Rev. 11-2018) Page 2
Section references are to the Internal Revenue Code unless otherwise noted. Effective period of exemption. An approved exemption granted to
employers and employees is effective on the first day of the first quarter after
Future Developments the quarter in which Form 4029 is filed. An approved exemption granted to
For the latest information about developments related to Form 4029 and its self-employed individuals is effective when granted and applies for all years
instructions, such as legislation enacted after they were published, go to for which you satisfy therequirements. The exemption will continue as long
www.irs.gov/Form4029. as you (or in the case of wage payments, both the employee and employer)
continue to meet the exemption requirements.
General Instructions Signature. The completed Form 4029 must be signed and dated by the
applicant in Part I and by the authorized representative of the religious group/
Purpose of form.Form 4029 is used by members of recognizedreligious district/congregation in Part II.
groups to apply for exemption from social security andMedicare taxes. The How to show exemption from self-employment taxes on Form 1040. If
exemption is for individuals and partnerships(when all the partners have the IRS returned your copy of Form 4029 marked “Approved,” write
approved certification). “Exempt—Form 4029” on the “Self-employment tax” line.
Note: The election to waive social security benefits, including Medicare
benefits, applies to all wages and self-employment incomeearned before Instructions to Employers
and during the effective period of this exemption and is irrevocable for that
period. Employees without Form 4029 approval. If you have employees who do
Who may apply.You may apply for this exemption if you are a member of, not have an approved Form 4029, you must withhold theemployee’s share
and follow the teachings of, a recognized religious group (as defined below). of social security and Medicare taxes and pay theemployer’s share.
If you already have approval for exemption from self-employment taxes, you Reporting exempt wages.If you are a qualifying employer with oneor more
are considered to have met the requirements for exemption from social qualifying employees, you are not required to report wagesthat are exempt
security and Medicare taxes on wages and do not need to file this form. under section 3127. Do not include these wages for social security and
You are not eligible for this exemption if you received social security Medicare tax purposes on Form 941, Employer’sQUARTERLY Federal Tax
benefits or payments, or if anyone else received these benefits or payments Return; Form 943, Employer’s Annual TaxReturn for Agricultural Employees;
based on your wages or self-employment income. However, you can file or on Form 944, Employer’sANNUAL Federal Tax Return. If you have
Form 4029 and be considered for approval if you paid back any benefits you received an approved Form4029, check the box on line 4 of Form 941 (line 3
received. of Form 944) and write “Form 4029” in the empty space below the check
box. If you fileForm 943 and have received an approved Form 4029, write
Recognized religious group. A recognized religious group must meet all the “Form4029” to the left of the wage entry spaces for Total wages subject to
following requirements. social security taxes and Total wages subject to Medicare taxes.
• It is conscientiously opposed to accepting benefits of any private or public Preparation of Form W-2. When you prepare Form W-2 for aqualifying
insurance that makes payments in the event of death, disability, old age, or employee, enter “Form 4029” in the box marked “Other.” Do not make any
retirement; makes payments for the cost of medical care; or provides entries in the boxes for Social security wages,Medicare wages and tips,
services for medical care (including social security and Medicare benefits). Social security tax withheld, or Medicaretax withheld for these employees.
• It has provided a reasonable level of living for its dependent members.
• It has existed continuously since December 31, 1950. Privacy Act and Paperwork Reduction Act Notice. We ask for the
Certification. In order to complete the certification portion under Part I, information on this form to carry out the Internal Revenue laws of the United
you need to enter your religious group (on the first line) followed by the States. We need this information to ensure that you are complying with these
religious district or congregation (on the second line). For example, if you laws and to allow us to figure and to collect the right amount of tax. Applying
enter “Old Order Amish” as your religious group,then you would enter for an exemption from social security and Medicare taxes is voluntary.
“Conewango Valley North District,” “Conewango Valley West District,” etc., Providing the requested information, however, is mandatory if you apply for
on the second line as the district. However, if you are Anabaptist or the exemption. Our legal right to ask for the information requested on this
Mennonite, enter the nameof your religious group as “Unaffiliated Mennonite form is Internal Revenue Code sections 6001, 6011, 6012(a), and 6109. Code
Churches” or“Eastern Pennsylvania Mennonite Church,” etc., and the section 6109 requires that you provide your social security number on what
congregation as “Antrim Mennonite Church (Anabaptist)” or “Bethel you file. If you fail to provide all or part of the information requested on Form
Mennonite Church (Mennonite),” on the second line. 4029, your application may be denied. If you provide false or fraudulent
information, you may be subject to penalties.
When to file. File Form 4029 when you want to apply for exemptionfrom Generally, tax returns and return information are confidential, as required
social security and Medicare taxes. This is a one-time election.Keep your by section 6103. However, section 6103 allows or requires the Internal
approved copy of Form 4029 for your permanent records. Revenue Service to disclose or give the information shown on your tax return
Where to file. Send the original and two copies of Form 4029 to: to others as described in the Code. For example, we may disclose your tax
Social Security Administration information to the Department of Justice for civil and criminal litigation, and
Security Records Branch to cities, states, the District of Columbia, and U.S. commonwealths and
Attn:Religious Exemption Unit possessions for use in administering their tax laws. We may also disclose
P.O. Box 7 this information to other countries under a tax treaty, to federal and state
Boyers, PA 16020 agencies to enforce federal nontax criminal laws, or to federal law
If you areno longer a member or no longer follow the teachings of the enforcement and intelligence agencies to combat terrorism.
religious group, your exemption is no longer effective. Notify the Internal Please keep this notice with your records. It may help you if we ask for
Revenue Service by sending a letter to: other information. If you have any questions about the rules for filing and
Department of the Treasury giving information, please call or visit any Internal Revenue Service office.
Internal Revenue Service Center The time needed to complete and file this form will vary depending on
Philadelphia, PA 19255-0733 individual circumstances. The estimated average time is: Recordkeeping, 6
Social security number. Enter your social security number on line 2.If you min.; Learning about the law or the form, 19 min.; Preparing the form, 18
do not have a social security number, file Form SS-5, Application for a Social min.; Copying, assembling, andsending the form to the SSA, 16 min.
Security Card, at your local social security office. You can get Form SS-5 If you have comments concerning the accuracy of these time estimates or
from the SSA website at www.ssa.gov/forms/ss-5.pdf, at SSA offices, or by suggestions for making this form simpler, we would be happy to hear from
calling 1-800-772-1213. you. You can send us comments from www.irs.gov/FormComments. Or you
can send your comments to Internal Revenue Service, Tax Forms and
Publications Division, 1111 Constitution Ave. NW, IR-6526, Washington, DC
20224. Do not send the form to this address. Instead, see Where to file,
earlier.

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