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                                                    Application for Exemption From Social Security and 
                                                                                                                                                                    OMB No. 1545-0064 
Form  4029                                                      Medicare Taxes and Waiver of Benefits
(Rev. September 2014)                                   ▶ Information about Form 4029 and its instructions is at  www.irs.gov/form4029. 
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                                                   ▶ Do not use prior versions of this form. 
Caution: Approval of Form 4029 exempts you from social security and Medicare taxes only. The exemption doesnot 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 (Print or type) 
                            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 

                            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 in 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. 9-2014)

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Form 4029 (Rev. 9-2014) Page 2
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/
Section references are to the Internal Revenue Code. district/congregation in Part II.
Purpose of form.Form 4029 is used by members of recognized religious How to show exemption from self-employment taxes on Form 1040. If
groups to apply for exemption from social security and Medicare taxes. The the IRS returned your copy of Form 4029 marked “Approved,” write “Form
exemption is for individuals and partnerships (when all the partners have 4029” on the “Self-employment tax” line in the Other Taxes section of Form
approved certification). 1040, page 2.
Note. The election to waive social security benefits, including Medicare
benefits, applies to all wages and self-employment income earned before Instructions to Employers
and during the effective period of this exemption and is irrevocable for that Employees without Form 4029 approval. If you have employees who do
period. not have an approved Form 4029, you must withhold the employee’s share
Who may apply.You may apply for this exemption if you are a member of, of social security and Medicare taxes and pay the employer’s share.
and follow the teachings of, a recognized religious group (as defined below). Reporting exempt wages.If you are a qualifying employer with one or more
If you already have approval for exemption from self-employment taxes, you qualifying employees, you are not required to report wages that are exempt
are considered to have met the requirements for exemption from social under section 3127. Do not include these wages for social security and
security and Medicare taxes on wages and do not need to file this form. Medicare tax purposes on Form 941, Employer’s QUARTERLY Federal Tax
You are not eligible for this exemption if you received social security Return, Form 943, Employer’s Annual Tax Return for Agricultural Employees,
benefits or payments, or if anyone else received these benefits or payments or on Form 944, Employer’s ANNUAL Federal Tax Return. If you have
based on your wages or self-employment income. However, you can file received an approved Form 4029, check the box on line 4 of Form 941 (line
Form 4029 and be considered for approval if you paid back any benefits you 3 of Form 944) and write “Form 4029” in the empty space below the check
received. box. If you file Form 943 and have received an approved Form 4029, write
Recognized religious group. A recognized religious group must meet all the “Form 4029” 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 a qualifying
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 Medicare tax 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
information on this form to carry out the Internal Revenue laws of the United
Certification. In order to complete the certification portion under Part I, States. We need this information to ensure that you are complying with these
you need to enter your religious group (on the first line) followed by the laws and to allow us to figure and to collect the right amount of tax. Applying
religious district or congregation (on the second line). For example, if you for an exemption from social security and Medicare taxes is voluntary.
enter “Old Order Amish” as your religious group, then you would enter Providing the requested information, however, is mandatory if you apply for
“Conewango Valley North District,” “Conewango Valley West District,” etc., the exemption. Our legal right to ask for the information requested on this
on the second line as the district. However, if you are Anabaptist or form is Internal Revenue Code sections 6001, 6011, 6012(a) and 6109. Code
Mennonite, enter the name of your religious group as “Unaffiliated Mennonite section 6109 requires that you provide your social security number on what
Churches” or “Eastern Pennsylvania Mennonite Church,” etc., and the you file. If you fail to provide all or part of the information requested on Form
congregation as “Antrim Mennonite Church (Anabaptist)” or “Bethel 4029, your application may be denied. If you provide false or fraudulent
Mennonite Church (Mennonite),” on the second line. information, you may be subject to penalties.
When to file. File Form 4029 when you want to apply for exemption from Generally, tax returns and return information are confidential, as stated in
social security and Medicare taxes. This is a one-time election. Keep your section 6103. However, section 6103 allows or requires the Internal Revenue
approved copy of Form 4029 for your permanent records. Service to disclose or give the information shown on your tax return to others
Where to file. Send the original and two copies of Form 4029 to: as described in the Code. For example, we may disclose your tax information
to the Department of Justice to enforce the tax laws, both civil and criminal,
Social Security Administration to cities, states, the District of Columbia, U.S. commonwealths or
Security Records Branch, possessions for use in administering their tax laws. We may also disclose
Attn: Religious Exemption Unit this information to other countries under a tax treaty, to federal and state
P.O. Box 7 agencies to enforce federal nontax criminal laws, or to federal law
Boyers, PA 16020 enforcement and intelligence agencies to combat terrorism.
If you are no longer a member or no longer follow the teachings of the Please keep this notice with your records. It may help you if we ask for
religious group, your exemption is no longer effective. Notify the Internal other information. If you have any questions about the rules for filing and
Revenue Service by sending a letter to: giving information, please call or visit any Internal Revenue Service office.
Department of the Treasury The time needed to complete and file this form will vary depending on
Internal Revenue Service Center individual circumstances. The estimated average time is: Recordkeeping, 6
Philadelphia, PA 19255-0733 min.; Learning about the law or the form, 19 min.; Preparing the form, 18
Social security number. Enter your social security number on line 2. If you min.; Copying, assembling, and sending the form to the SSA,16 min.
do not have a social security number, file Form SS-5, Application for a Social If you have comments concerning the accuracy of these time estimates or
Security Card, at your local social security office. You can order Form SS-5 suggestions for making this form simpler, we would be happy to hear from
by calling 1-800-772-1213 or by visiting the website for Social Security at you. You can send us comments from www.irs.gov/formspubs. Click on
www.socialsecurity.gov. More Information and then click on Give us feedback. Or you can send your
Effective period of exemption. An approved exemption granted to comments to Internal Revenue Service, Tax Forms and Publications Division,
employers and employees is effective on the first day of the first quarter after 1111 Constitution Ave. NW, IR-6526, Washington, DC 20224. Do not send
the quarter in which Form 4029 is filed. An approved exemption granted to the form to this address. Instead, see Where to file, earlier.
self-employed individuals is effective when granted and applies for all years
for which you satisfy the requirements. The exemption will continue as long
as you, or in the case of wage payments, both the employee and employer
continue to meet the exemption requirements.

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