Question	Answer
Form Name	Irs Gov Ptin Renewal
Form Length	3 pages
Fillable?	Yes
Fillable fields	1
Avg. time to fill out	57 sec
Other names	Form W-12 (Rev. May 2021). IRS Paid Preparer Tax Identification Number (PTIN) Application and Renewal

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/
	Application/	indicate below whether you want your PTIN to be valid for the current calendar year or the next calendar year.
	Renewal
	Renewal	Current calendar year				Next calendar year
		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.					-	-		/	/
		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
	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

	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)

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:

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
	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
	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	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.

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

	Under penalties of perjury, I declare that I have examined this application and to the best of my knowledge and belief, it
Sign	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.
Here		Your signature (Please use blue or black ink)	Date (MM/DD/YYYY)
			/	/

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