1224 Form W-7 (PDF) — verbatim text

Official source: IRS Forms, Instructions & Publications (https://www.irs.gov/pub/irs-pdf/fw7.pdf), retrieved 2026-10-03. U.S. Government work (17 U.S.C. § 105).

Reason you’re submitting Form W-7. Read the instructions for the box you check. Caution: If you check box b, c, d, e, f, or g, you must file a U.S. federal tax return with Form W-7 unless you meet one of the exceptions (see instructions).

a Nonresident alien required to get an ITIN to claim tax treaty benefit (you must also check and complete box h (see instructions)) b Nonresident alien filing a U.S. federal tax return c U.S. resident alien ( based on days present in the United States ) filing a U.S. federal tax return d Dependent of U.S. citizen/resident alien If d, enter relationship to U.S. citizen/resident alien (see instructions)

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If d, enter relationship to U.S. citizen/resident alien (see instructions)

e Spouse of U.S. citizen/resident alien If d or e, enter name and SSN/ITIN of U.S. citizen/resident alien (see instructions)

f Nonresident alien student, professor, or researcher filing a U.S. federal tax return or claiming an exception (if claiming an exception, you must also check and complete box h (see instructions))

g Dependent/spouse of a nonresident alien holding a U.S. visa

h Other (see instructions)

Additional informatio	on for a and f: Enter treaty country			and treaty article						number
Name (see instructions) Name at birth if different . . .	1a First name	1a First name	1a First name	Middle name	Middle name	Middle name	Middle name	Middle name	Middle name	Last name	Last name	Last name	Last name	Last name	Last name	Last name
Name (see instructions) Name at birth if different . . .	1b First name	1b First name	1b First name	Middle name	Middle name	Middle name	Middle name	Middle name	Middle name	Last name	Last name	Last name	Last name	Last name	Last name	Last name
Applicant’s Mailing Address	2 Street address, apartment number, or rural route number.If you have a P.O. box, see separate instructions.	2 Street address, apartment number, or rural route number.If you have a P.O. box, see separate instructions.	2 Street address, apartment number, or rural route number.If you have a P.O. box, see separate instructions.	2 Street address, apartment number, or rural route number.If you have a P.O. box, see separate instructions.	2 Street address, apartment number, or rural route number.If you have a P.O. box, see separate instructions.	2 Street address, apartment number, or rural route number.If you have a P.O. box, see separate instructions.	2 Street address, apartment number, or rural route number.If you have a P.O. box, see separate instructions.	2 Street address, apartment number, or rural route number.If you have a P.O. box, see separate instructions.	2 Street address, apartment number, or rural route number.If you have a P.O. box, see separate instructions.	2 Street address, apartment number, or rural route number.If you have a P.O. box, see separate instructions.	2 Street address, apartment number, or rural route number.If you have a P.O. box, see separate instructions.	2 Street address, apartment number, or rural route number.If you have a P.O. box, see separate instructions.	2 Street address, apartment number, or rural route number.If you have a P.O. box, see separate instructions.	2 Street address, apartment number, or rural route number.If you have a P.O. box, see separate instructions.	2 Street address, apartment number, or rural route number.If you have a P.O. box, see separate instructions.	2 Street address, apartment number, or rural route number.If you have a P.O. box, see separate instructions.
Applicant’s Mailing Address	City or town, state or province, and country. Include ZIP code or postal code where appropriate.	City or town, state or province, and country. Include ZIP code or postal code where appropriate.	City or town, state or province, and country. Include ZIP code or postal code where appropriate.	City or town, state or province, and country. Include ZIP code or postal code where appropriate.	City or town, state or province, and country. Include ZIP code or postal code where appropriate.	City or town, state or province, and country. Include ZIP code or postal code where appropriate.	City or town, state or province, and country. Include ZIP code or postal code where appropriate.	City or town, state or province, and country. Include ZIP code or postal code where appropriate.	City or town, state or province, and country. Include ZIP code or postal code where appropriate.	City or town, state or province, and country. Include ZIP code or postal code where appropriate.	City or town, state or province, and country. Include ZIP code or postal code where appropriate.	City or town, state or province, and country. Include ZIP code or postal code where appropriate.	City or town, state or province, and country. Include ZIP code or postal code where appropriate.	City or town, state or province, and country. Include ZIP code or postal code where appropriate.	City or town, state or province, and country. Include ZIP code or postal code where appropriate.	City or town, state or province, and country. Include ZIP code or postal code where appropriate.
Foreign (non-U.S.) Address (see instructions)	3 Street address, apartment number, or rural route number.Don’t use a P.O. box number.	3 Street address, apartment number, or rural route number.Don’t use a P.O. box number.	3 Street address, apartment number, or rural route number.Don’t use a P.O. box number.	3 Street address, apartment number, or rural route number.Don’t use a P.O. box number.	3 Street address, apartment number, or rural route number.Don’t use a P.O. box number.	3 Street address, apartment number, or rural route number.Don’t use a P.O. box number.	3 Street address, apartment number, or rural route number.Don’t use a P.O. box number.	3 Street address, apartment number, or rural route number.Don’t use a P.O. box number.	3 Street address, apartment number, or rural route number.Don’t use a P.O. box number.	3 Street address, apartment number, or rural route number.Don’t use a P.O. box number.	3 Street address, apartment number, or rural route number.Don’t use a P.O. box number.	3 Street address, apartment number, or rural route number.Don’t use a P.O. box number.	3 Street address, apartment number, or rural route number.Don’t use a P.O. box number.	3 Street address, apartment number, or rural route number.Don’t use a P.O. box number.	3 Street address, apartment number, or rural route number.Don’t use a P.O. box number.	3 Street address, apartment number, or rural route number.Don’t use a P.O. box number.
Foreign (non-U.S.) Address (see instructions)	City or town, state or province, and country. Include postal code where appropriate.	City or town, state or province, and country. Include postal code where appropriate.	City or town, state or province, and country. Include postal code where appropriate.	City or town, state or province, and country. Include postal code where appropriate.	City or town, state or province, and country. Include postal code where appropriate.	City or town, state or province, and country. Include postal code where appropriate.	City or town, state or province, and country. Include postal code where appropriate.	City or town, state or province, and country. Include postal code where appropriate.	City or town, state or province, and country. Include postal code where appropriate.	City or town, state or province, and country. Include postal code where appropriate.	City or town, state or province, and country. Include postal code where appropriate.	City or town, state or province, and country. Include postal code where appropriate.	City or town, state or province, and country. Include postal code where appropriate.	City or town, state or province, and country. Include postal code where appropriate.	City or town, state or province, and country. Include postal code where appropriate.	City or town, state or province, and country. Include postal code where appropriate.
Birth Information	4 Date of birth (month / day / year) / /	4 Date of birth (month / day / year) / /	Country of birth	Country of birth	Country of birth	Country of birth	Country of birth	City and state or province (optional)	City and state or province (optional)	City and state or province (optional)	City and state or province (optional)	5 Male Female	5 Male Female	5 Male Female	5 Male Female	5 Male Female
Other Information	6a Country(ies) of citizenship	6b Foreign tax I.D. number (if any)	6b Foreign tax I.D. number (if any)	6b Foreign tax I.D. number (if any)	6b Foreign tax I.D. number (if any)	6b Foreign tax I.D. number (if any)	6c Type of U.S. visa (if any), number, and expiration date	6c Type of U.S. visa (if any), number, and expiration date	6c Type of U.S. visa (if any), number, and expiration date	6c Type of U.S. visa (if any), number, and expiration date	6c Type of U.S. visa (if any), number, and expiration date	6c Type of U.S. visa (if any), number, and expiration date	6c Type of U.S. visa (if any), number, and expiration date	6c Type of U.S. visa (if any), number, and expiration date	6c Type of U.S. visa (if any), number, and expiration date	6c Type of U.S. visa (if any), number, and expiration date
Other Information	6d Identification document(s) submitted. (Complete for the first document submitted. For multiple documents, see instructions) Passport Driver’s license/State I.D. USCIS documentation Other Issued by: Number: / / Exp. date: Date of entry into the United States (MM/DD/YYYY): / /	6d Identification document(s) submitted. (Complete for the first document submitted. For multiple documents, see instructions) Passport Driver’s license/State I.D. USCIS documentation Other Issued by: Number: / / Exp. date: Date of entry into the United States (MM/DD/YYYY): / /	6d Identification document(s) submitted. (Complete for the first document submitted. For multiple documents, see instructions) Passport Driver’s license/State I.D. USCIS documentation Other Issued by: Number: / / Exp. date: Date of entry into the United States (MM/DD/YYYY): / /	6d Identification document(s) submitted. (Complete for the first document submitted. For multiple documents, see instructions) Passport Driver’s license/State I.D. USCIS documentation Other Issued by: Number: / / Exp. date: Date of entry into the United States (MM/DD/YYYY): / /	6d Identification document(s) submitted. (Complete for the first document submitted. For multiple documents, see instructions) Passport Driver’s license/State I.D. USCIS documentation Other Issued by: Number: / / Exp. date: Date of entry into the United States (MM/DD/YYYY): / /	6d Identification document(s) submitted. (Complete for the first document submitted. For multiple documents, see instructions) Passport Driver’s license/State I.D. USCIS documentation Other Issued by: Number: / / Exp. date: Date of entry into the United States (MM/DD/YYYY): / /	6d Identification document(s) submitted. (Complete for the first document submitted. For multiple documents, see instructions) Passport Driver’s license/State I.D. USCIS documentation Other Issued by: Number: / / Exp. date: Date of entry into the United States (MM/DD/YYYY): / /	6d Identification document(s) submitted. (Complete for the first document submitted. For multiple documents, see instructions) Passport Driver’s license/State I.D. USCIS documentation Other Issued by: Number: / / Exp. date: Date of entry into the United States (MM/DD/YYYY): / /	6d Identification document(s) submitted. (Complete for the first document submitted. For multiple documents, see instructions) Passport Driver’s license/State I.D. USCIS documentation Other Issued by: Number: / / Exp. date: Date of entry into the United States (MM/DD/YYYY): / /	6d Identification document(s) submitted. (Complete for the first document submitted. For multiple documents, see instructions) Passport Driver’s license/State I.D. USCIS documentation Other Issued by: Number: / / Exp. date: Date of entry into the United States (MM/DD/YYYY): / /	6d Identification document(s) submitted. (Complete for the first document submitted. For multiple documents, see instructions) Passport Driver’s license/State I.D. USCIS documentation Other Issued by: Number: / / Exp. date: Date of entry into the United States (MM/DD/YYYY): / /	6d Identification document(s) submitted. (Complete for the first document submitted. For multiple documents, see instructions) Passport Driver’s license/State I.D. USCIS documentation Other Issued by: Number: / / Exp. date: Date of entry into the United States (MM/DD/YYYY): / /	6d Identification document(s) submitted. (Complete for the first document submitted. For multiple documents, see instructions) Passport Driver’s license/State I.D. USCIS documentation Other Issued by: Number: / / Exp. date: Date of entry into the United States (MM/DD/YYYY): / /	6d Identification document(s) submitted. (Complete for the first document submitted. For multiple documents, see instructions) Passport Driver’s license/State I.D. USCIS documentation Other Issued by: Number: / / Exp. date: Date of entry into the United States (MM/DD/YYYY): / /	6d Identification document(s) submitted. (Complete for the first document submitted. For multiple documents, see instructions) Passport Driver’s license/State I.D. USCIS documentation Other Issued by: Number: / / Exp. date: Date of entry into the United States (MM/DD/YYYY): / /	6d Identification document(s) submitted. (Complete for the first document submitted. For multiple documents, see instructions) Passport Driver’s license/State I.D. USCIS documentation Other Issued by: Number: / / Exp. date: Date of entry into the United States (MM/DD/YYYY): / /
Other Information	6e Have you previously received an ITIN or an Internal Revenue Service Number (IRSN)? No/Don’t know.Skip line 6f. Yes. Complete line 6f. If more than one, list on a sheet and attach to this form (see instructions).	6e Have you previously received an ITIN or an Internal Revenue Service Number (IRSN)? No/Don’t know.Skip line 6f. Yes. Complete line 6f. If more than one, list on a sheet and attach to this form (see instructions).	6e Have you previously received an ITIN or an Internal Revenue Service Number (IRSN)? No/Don’t know.Skip line 6f. Yes. Complete line 6f. If more than one, list on a sheet and attach to this form (see instructions).	6e Have you previously received an ITIN or an Internal Revenue Service Number (IRSN)? No/Don’t know.Skip line 6f. Yes. Complete line 6f. If more than one, list on a sheet and attach to this form (see instructions).	6e Have you previously received an ITIN or an Internal Revenue Service Number (IRSN)? No/Don’t know.Skip line 6f. Yes. Complete line 6f. If more than one, list on a sheet and attach to this form (see instructions).	6e Have you previously received an ITIN or an Internal Revenue Service Number (IRSN)? No/Don’t know.Skip line 6f. Yes. Complete line 6f. If more than one, list on a sheet and attach to this form (see instructions).	6e Have you previously received an ITIN or an Internal Revenue Service Number (IRSN)? No/Don’t know.Skip line 6f. Yes. Complete line 6f. If more than one, list on a sheet and attach to this form (see instructions).	6e Have you previously received an ITIN or an Internal Revenue Service Number (IRSN)? No/Don’t know.Skip line 6f. Yes. Complete line 6f. If more than one, list on a sheet and attach to this form (see instructions).	6e Have you previously received an ITIN or an Internal Revenue Service Number (IRSN)? No/Don’t know.Skip line 6f. Yes. Complete line 6f. If more than one, list on a sheet and attach to this form (see instructions).	6e Have you previously received an ITIN or an Internal Revenue Service Number (IRSN)? No/Don’t know.Skip line 6f. Yes. Complete line 6f. If more than one, list on a sheet and attach to this form (see instructions).	6e Have you previously received an ITIN or an Internal Revenue Service Number (IRSN)? No/Don’t know.Skip line 6f. Yes. Complete line 6f. If more than one, list on a sheet and attach to this form (see instructions).	6e Have you previously received an ITIN or an Internal Revenue Service Number (IRSN)? No/Don’t know.Skip line 6f. Yes. Complete line 6f. If more than one, list on a sheet and attach to this form (see instructions).	6e Have you previously received an ITIN or an Internal Revenue Service Number (IRSN)? No/Don’t know.Skip line 6f. Yes. Complete line 6f. If more than one, list on a sheet and attach to this form (see instructions).	6e Have you previously received an ITIN or an Internal Revenue Service Number (IRSN)? No/Don’t know.Skip line 6f. Yes. Complete line 6f. If more than one, list on a sheet and attach to this form (see instructions).	6e Have you previously received an ITIN or an Internal Revenue Service Number (IRSN)? No/Don’t know.Skip line 6f. Yes. Complete line 6f. If more than one, list on a sheet and attach to this form (see instructions).	6e Have you previously received an ITIN or an Internal Revenue Service Number (IRSN)? No/Don’t know.Skip line 6f. Yes. Complete line 6f. If more than one, list on a sheet and attach to this form (see instructions).
Other Information	6f Enter ITIN and/or IRSN ITIN – – IRSN – – and name under which it was issued First name Middle name Last name	6f Enter ITIN and/or IRSN ITIN – – IRSN – – and name under which it was issued First name Middle name Last name	6f Enter ITIN and/or IRSN ITIN – – IRSN – – and name under which it was issued First name Middle name Last name	6f Enter ITIN and/or IRSN ITIN – – IRSN – – and name under which it was issued First name Middle name Last name	6f Enter ITIN and/or IRSN ITIN – – IRSN – – and name under which it was issued First name Middle name Last name	6f Enter ITIN and/or IRSN ITIN – – IRSN – – and name under which it was issued First name Middle name Last name	6f Enter ITIN and/or IRSN ITIN – – IRSN – – and name under which it was issued First name Middle name Last name	6f Enter ITIN and/or IRSN ITIN – – IRSN – – and name under which it was issued First name Middle name Last name	6f Enter ITIN and/or IRSN ITIN – – IRSN – – and name under which it was issued First name Middle name Last name	6f Enter ITIN and/or IRSN ITIN – – IRSN – – and name under which it was issued First name Middle name Last name	6f Enter ITIN and/or IRSN ITIN – – IRSN – – and name under which it was issued First name Middle name Last name	6f Enter ITIN and/or IRSN ITIN – – IRSN – – and name under which it was issued First name Middle name Last name
Other Information	6g Name of college/university or company (see instructions) City and state Length of stay	6g Name of college/university or company (see instructions) City and state Length of stay	6g Name of college/university or company (see instructions) City and state Length of stay	6g Name of college/university or company (see instructions) City and state Length of stay	6g Name of college/university or company (see instructions) City and state Length of stay	6g Name of college/university or company (see instructions) City and state Length of stay	6g Name of college/university or company (see instructions) City and state Length of stay	6g Name of college/university or company (see instructions) City and state Length of stay	6g Name of college/university or company (see instructions) City and state Length of stay	6g Name of college/university or company (see instructions) City and state Length of stay	6g Name of college/university or company (see instructions) City and state Length of stay	6g Name of college/university or company (see instructions) City and state Length of stay	6g Name of college/university or company (see instructions) City and state Length of stay	6g Name of college/university or company (see instructions) City and state Length of stay	6g Name of college/university or company (see instructions) City and state Length of stay	6g Name of college/university or company (see instructions) City and state Length of stay
Sign Here Keep a copy for your records.	Under penalties of perjury, I (applicant/delegate/acceptance agent) declare that I have examined this application, including accompanying documentation and statements, and to the best of my knowledge and belief, it is true, correct, and complete. I authorize the IRS to share information with my acceptance agent in order to perfect this Form W-7, Application for IRS Individual Taxpayer Identification Number. Signature of applicant (if delegate, see instructions) Date (month / day / year) / / Phone number	Under penalties of perjury, I (applicant/delegate/acceptance agent) declare that I have examined this application, including accompanying documentation and statements, and to the best of my knowledge and belief, it is true, correct, and complete. I authorize the IRS to share information with my acceptance agent in order to perfect this Form W-7, Application for IRS Individual Taxpayer Identification Number. Signature of applicant (if delegate, see instructions) Date (month / day / year) / / Phone number	Under penalties of perjury, I (applicant/delegate/acceptance agent) declare that I have examined this application, including accompanying documentation and statements, and to the best of my knowledge and belief, it is true, correct, and complete. I authorize the IRS to share information with my acceptance agent in order to perfect this Form W-7, Application for IRS Individual Taxpayer Identification Number. Signature of applicant (if delegate, see instructions) Date (month / day / year) / / Phone number	Under penalties of perjury, I (applicant/delegate/acceptance agent) declare that I have examined this application, including accompanying documentation and statements, and to the best of my knowledge and belief, it is true, correct, and complete. I authorize the IRS to share information with my acceptance agent in order to perfect this Form W-7, Application for IRS Individual Taxpayer Identification Number. Signature of applicant (if delegate, see instructions) Date (month / day / year) / / Phone number	Under penalties of perjury, I (applicant/delegate/acceptance agent) declare that I have examined this application, including accompanying documentation and statements, and to the best of my knowledge and belief, it is true, correct, and complete. I authorize the IRS to share information with my acceptance agent in order to perfect this Form W-7, Application for IRS Individual Taxpayer Identification Number. Signature of applicant (if delegate, see instructions) Date (month / day / year) / / Phone number	Under penalties of perjury, I (applicant/delegate/acceptance agent) declare that I have examined this application, including accompanying documentation and statements, and to the best of my knowledge and belief, it is true, correct, and complete. I authorize the IRS to share information with my acceptance agent in order to perfect this Form W-7, Application for IRS Individual Taxpayer Identification Number. Signature of applicant (if delegate, see instructions) Date (month / day / year) / / Phone number	Under penalties of perjury, I (applicant/delegate/acceptance agent) declare that I have examined this application, including accompanying documentation and statements, and to the best of my knowledge and belief, it is true, correct, and complete. I authorize the IRS to share information with my acceptance agent in order to perfect this Form W-7, Application for IRS Individual Taxpayer Identification Number. Signature of applicant (if delegate, see instructions) Date (month / day / year) / / Phone number	Under penalties of perjury, I (applicant/delegate/acceptance agent) declare that I have examined this application, including accompanying documentation and statements, and to the best of my knowledge and belief, it is true, correct, and complete. I authorize the IRS to share information with my acceptance agent in order to perfect this Form W-7, Application for IRS Individual Taxpayer Identification Number. Signature of applicant (if delegate, see instructions) Date (month / day / year) / / Phone number	Under penalties of perjury, I (applicant/delegate/acceptance agent) declare that I have examined this application, including accompanying documentation and statements, and to the best of my knowledge and belief, it is true, correct, and complete. I authorize the IRS to share information with my acceptance agent in order to perfect this Form W-7, Application for IRS Individual Taxpayer Identification Number. Signature of applicant (if delegate, see instructions) Date (month / day / year) / / Phone number	Under penalties of perjury, I (applicant/delegate/acceptance agent) declare that I have examined this application, including accompanying documentation and statements, and to the best of my knowledge and belief, it is true, correct, and complete. I authorize the IRS to share information with my acceptance agent in order to perfect this Form W-7, Application for IRS Individual Taxpayer Identification Number. Signature of applicant (if delegate, see instructions) Date (month / day / year) / / Phone number	Under penalties of perjury, I (applicant/delegate/acceptance agent) declare that I have examined this application, including accompanying documentation and statements, and to the best of my knowledge and belief, it is true, correct, and complete. I authorize the IRS to share
information with my acceptance agent in order to perfect this Form W-7, Application for IRS Individual Taxpayer Identification Number. Signature of applicant (if delegate, see instructions) Date (month / day / year) / / Phone number	Under penalties of perjury, I (applicant/delegate/acceptance agent) declare that I have examined this application, including accompanying documentation and statements, and to the best of my knowledge and belief, it is true, correct, and complete. I authorize the IRS to share information with my acceptance agent in order to perfect this Form W-7, Application for IRS Individual Taxpayer Identification Number. Signature of applicant (if delegate, see instructions) Date (month / day / year) / / Phone number	Under penalties of perjury, I (applicant/delegate/acceptance agent) declare that I have examined this application, including accompanying documentation and statements, and to the best of my knowledge and belief, it is true, correct, and complete. I authorize the IRS to share information with my acceptance agent in order to perfect this Form W-7, Application for IRS Individual Taxpayer Identification Number. Signature of applicant (if delegate, see instructions) Date (month / day / year) / / Phone number	Under penalties of perjury, I (applicant/delegate/acceptance agent) declare that I have examined this application, including accompanying documentation and statements, and to the best of my knowledge and belief, it is true, correct, and complete. I authorize the IRS to share information with my acceptance agent in order to perfect this Form W-7, Application for IRS Individual Taxpayer Identification Number. Signature of applicant (if delegate, see instructions) Date (month / day / year) / / Phone number	Under penalties of perjury, I (applicant/delegate/acceptance agent) declare that I have examined this application, including accompanying documentation and statements, and to the best of my knowledge and belief, it is true, correct, and complete. I authorize the IRS to share information with my acceptance agent in order to perfect this Form W-7, Application for IRS Individual Taxpayer Identification Number. Signature of applicant (if delegate, see instructions) Date (month / day / year) / / Phone number	Under penalties of perjury, I (applicant/delegate/acceptance agent) declare that I have examined this application, including accompanying documentation and statements, and to the best of my knowledge and belief, it is true, correct, and complete. I authorize the IRS to share information with my acceptance agent in order to perfect this Form W-7, Application for IRS Individual Taxpayer Identification Number. Signature of applicant (if delegate, see instructions) Date (month / day / year) / / Phone number

Additional informatio	on for a and f: Enter treaty country			and treaty article						number
Sign Here Keep a copy for your records.	Name of delegate, if applicable (type or print)	Name of delegate, if applicable (type or print)	Name of delegate, if applicable (type or print)	Name of delegate, if applicable (type or print)	Name of delegate, if applicable (type or print)	Delegate’s relationship to applicant Parent Power of attorney Court-appointed guardian	Delegate’s relationship to applicant Parent Power of attorney Court-appointed guardian	Delegate’s relationship to applicant Parent Power of attorney Court-appointed guardian	Delegate’s relationship to applicant Parent Power of attorney Court-appointed guardian	Delegate’s relationship to applicant Parent Power of attorney Court-appointed guardian	Delegate’s relationship to applicant Parent Power of attorney Court-appointed guardian	Delegate’s relationship to applicant Parent Power of attorney Court-appointed guardian	Delegate’s relationship to applicant Parent Power of attorney Court-appointed guardian	Delegate’s relationship to applicant Parent Power of attorney Court-appointed guardian	Delegate’s relationship to applicant Parent Power of attorney Court-appointed guardian	Delegate’s relationship to applicant Parent Power of attorney Court-appointed guardian
Acceptance Agent’s Use ONLY	Signature	Signature	Signature	Signature	Signature	Date (month / day / year) / /	Date (month / day / year) / /	Date (month / day / year) / /	Date (month / day / year) / /	Phone	Phone	Phone	Phone	Phone	Phone	Phone
Acceptance Agent’s Use ONLY	Signature	Signature	Signature	Signature	Signature	Date (month / day / year) / /	Date (month / day / year) / /	Date (month / day / year) / /	Date (month / day / year) / /	Fax	Fax	Fax	Fax	Fax	Fax	Fax
Acceptance Agent’s Use ONLY	Name and title (type or print)	Name and title (type or print)	Name and title (type or print)	Name and title (type or print)	Name of company	Name of company	Name of company	Name of company	EIN	EIN	PTIN	PTIN	PTIN	PTIN	PTIN	PTIN
Acceptance Agent’s Use ONLY	Name and title (type or print)	Name and title (type or print)	Name and title (type or print)	Name and title (type or print)	Name of company	Name of company	Name of company	Name of company	Office code	Office code	Office code	Office code	Office code	Office code	Office code	Office code

Exceptions & meaning →