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IRS Paid Preparer Tax Identification Number (PTIN)
Form W-12 OMB No. 1545-2190
(Rev. May 2021) Application and Renewal
Department of the Treasury ▶ Go to www.irs.gov/FormW12 for instructions and the latest information.
Internal Revenue Service
1 Name and PTIN First name Middle name Last name
(Print in ink or
Type)
Initial application Renewal application (Enter PTIN: P )
2 Year of If you checked the “Initial application” box and are submitting this form between October 1 and December 31,
Application/ indicate below whether you want your PTIN to be valid for the current calendar year or the next calendar year.
Renewal
Current calendar year Next calendar year
Prior year(s) (YYYY): Check box(es) below for the prior year(s) you are renewing your PTIN. See line 2
instructions for additional guidance. If you are applying for a prior year(s), write each year(s) below. Use the
following format. (YYYY)
2020 2021 2022
Other prior year(s)
3 SSN and Date Provide your Social Security Number (SSN). If you SSN Date of birth (MM/DD/YYYY)
of Birth have an SSN, you are required to provide it. If you
- - / /
You must do not have an SSN, then check the N/A box.
provide your N/A
SSN or check Failure to provide your SSN or check the N/A
the N/A box box will result in your PTIN application being
rejected.
4 Personal Street address. Use a P.O. box number only if the post office does not deliver mail to your street address.
Mailing
Address and
Phone Number City or town, state or province, country, and ZIP or foreign postal code. Do not abbreviate name of country.

Phone Number ( ) -

5a Business Business address Check here if your business address is the same as your personal mailing address. If
Mailing different, enter it below.
Address and
Phone Number
City or town, state or province, country, and ZIP or foreign postal code. Do not abbreviate name of country.

Domestic business phone number International business phone number
( ) - EXT. +
b Business Are you self-employed or an owner, partner, or officer of a tax return preparation business? Yes No
Identification If “Yes,” then complete this line. If “No,” go to line 6.
Enter the business name.

Your CAF Number EIN EFIN
-
Website address (optional)

6 Email Address Enter 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. 5-2021)
For Internal Use Only
F:
E:
A:

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Form W-12 (Rev. 5-2021)                                                                                                     Page 2
7 Past Felony           Have you been convicted of a felony in the past 10 years?                                     Yes
  Convictions                                                                                                         No
  You must check 
  a box. If “Yes,”      If “Yes,” list the date and the type of felony conviction(s).
  you must 
  provide an 
  explanation.

If this is your initial application for a PTIN, continue to line 8. If you are renewing your PTIN, go to line 10.
8 Address of            Enter the address used on your last U.S. individual income tax return you filed.
  Your 
  Last U.S. 
  Individual  
  Income Tax            Check here if you have never filed a U.S. income tax return or do not have a U.S. income tax filing 
  Return Filed          requirement. See line 8 instructions for documents that must be submitted with this form and continue to  
                        line 10.
9 Filing Status         Single                                   Head of Household
  and Tax Year 
  on Last U.S.          Married filing jointly                   Qualifying widow(er) with dependent child
  Individual 
  Income Tax            Married filing separately                Tax Year (YYYY) 
  Return Filed
                        Note: If your last return was filed more than 4 years ago, see instructions.
10 Federal Tax          Are you current on both your individual and business federal taxes, including any corporate and employment 
  Compliance            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.                                                                Yes
                                                                                                                      No
                        If “No,” provide an explanation.

11 Data Security        I am aware that paid tax return preparers must have a data security plan to provide data and system security 
  Responsibilities      protections for all taxpayer information.
                                                                                                                 Form W-12 (Rev. 5-2021)

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Form W-12 (Rev. 5-2021) Page 3
12 Professional Check all that apply. Note: DO NOT check any professional credentials that are currently expired or
Credentials 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
13 Fees If you are applying for a PTIN or renewing your PTIN, your fee is $35.95. The fee is an application processing
fee and is nonrefundable. Full payment must be included with your application or it will be rejected. If your
application is incomplete and you do not supply the required information upon request, the IRS will be unable
to process your application. Make your check or money order payable to IRS Tax Pro PTIN Fee. Do not
paper clip, staple, or otherwise attach the payment to Form W-12. Separate payments are required for each
year you are applying for. No payment is due for 2020 and prior years.
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.
Sign ▲
Your signature (Please use blue or black ink) Date (MM/DD/YYYY)
Here
/ /
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
PO Box 380638
San Antonio, TX 78268
Note: Allow 4 to 6 weeks for processing of PTIN applications. For additional information, refer to the separate Instructions for
Form W-12.
For Internal Use Only Form W-12 (Rev. 5-2021)

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