1017 Form 15100 (PDF)

Official source: IRS Forms, Instructions & Publications (https://www.irs.gov/pub/irs-pdf/f15100.pdf), retrieved 2026-10-03. U.S. Government work (17 U.S.C. § 105).

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(October 2017)

Department of the Treasury - Internal Revenue Service

Complete this form, and fax or mail it to us at: Standard: Internal Revenue Service Stop 6182 Austin, TX 73301-0066

Fax number: (855) 250-1731

Overnight: Internal Revenue Service 3651 S. Interregional Hwy 35 Stop 6182 Austin, TX 78741

If you have any questions contact us at (737) 800-5511 (not toll free)

Contact Information

Name Taxpayer Identification Number

Name Taxpayer Identification Number

If you changed your address, write your new address below.

Indicate which of the following circumstances apply to you

I received a social security number for

Write the social security number assigned (Name of adoptee)

I need a 1 year extension for

ATIN

Reason (Name of adoptee) (ATIN assigned)

I couldn’t get a social security number for

ATIN

Reason (Name of adoptee) (ATIN assigned)

Status of your adoption

My adoption is final My adoption is pending

I am enclosing documents the placement agency or agent signed

Original signatures of adoptive parents

Name (print/type) Signature Date

Name (print/type) Signature Date

Catalog Number 69794D www.irs.gov Form 15100 (Rev. 10-2017)