To Be Completed by Applicant (Print or type)

Name of taxpayer 2

City or town, state, and ZIP code

Address (number, street, or P.O. box)

Self-Employment Tax for use by Ministers, Members of Religious Orders, and Christian Science Practitioners.

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 

(Month) (Year) (Day)

accepting benefits of any private or public insurance that makes payments in the event of death, disability, old age, or retirement; or makes 

the cost of medical care; or provides services for medical care. Public insurance includes any insurance system established by the Social Se

I request that I be exempted from paying social security and Medicare taxes on my earnings from self-employment under Internal Revenue 

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, f

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 

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

income to any other person. I certify that I have never received benefits or payments under the above titles, nor has anyone else r

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 g

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 Reven

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● My employees with respect to wages I may pay to them; and that if my employer’s exemption is no longer in effect, my exemption will en

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 und

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 year following the calendar year in which the exemption no longer meets the requirements of sectio

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 

Signature of Applicant Date 

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

(Please print or type) (Address) Signature of

Authorized Representative 

Social Security Administration Use Only

This religious group is recognized as being in existence continuously since December 31, 1950, as providing a reasonable lev

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 reasonabl

living for its dependent members, and/or as being conscientiously opposed to public or private insurance.

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.

For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 41277T Form 4029 

Part I

Part II

1 Social security num

3 Date of birth

4 Contact phone numb

( )

Print or type

Title Date 

5 Do not send me my Social Security Statement.

Signature of

Authorized SSA Representative 

Signature and Title of

Authorized IRS Representative 

Date 

Date When to file. File Form 4029 when you want to apply for exemption

from social security and Medicare taxes. This is a one-time election.

Keep your approved copy of Form 4029 for your permanent records.

Our authority to ask for information is Internal Revenu

sections 6001, 6011, and 6012(a) which require you to 

statement with us for any tax for which you are liable. Y

is mandatory under these sections. Section 6109 requir

provide your social security number on what you file. Th

know who you are, and can process your return and ot

You must fill in all parts of the tax form that apply to yo

not required to provide the information requested on a 

subject to the Paperwork Reduction Act unless the form 

valid OMB control number. Books or records relating to 

instructions must be retained as long as their contents 

material in the administration of any Internal Revenue la

Where to file. Send three copies of Form 4029 to: Attention: Form

4029 Process, Social Security Administration, Division of Earnings

Adjustments, Metro West, North Building, 300 N. Greene St.,

Baltimore, MD 21290. If you are no longer a member or no longer

follow the teachings of the religious group and want to revoke this

exemption, send a letter to Internal Revenue Service, Drop Point

849, Philadelphia, PA 19255.

Social security number. Enter your social security number on line 2.

If you do not have a social security number, file Form SS-5,

Application for a Social Security Card, at your local social security

office. You can order Form SS-5 by calling 1-800-772-1213 or by

visiting the website for Social Security at

www.SocialSecurityAdministration.gov.

If you have comments concerning the accuracy of th

estimates or suggestions for making this form simpler, w

happy to hear from you. You can write to the Internal R

Service, Tax Products Coordinating Committee,

SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW, IR-6

Washington, DC 20224. Do not send the form to this ad

Instead, see Where to file on this page.

Effective date of exemption. An approved exemption begins on the

first day of the first quarter after the quarter in which Form 4029 is

filed. 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.

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/district/congregation in Part II.

ppp

(when all the partners have approved certification).

How to show exemption from self-employment taxes on Form

1040. If the IRS returned your copy of Form 4029 marked

“Approved,” write “Form 4029” on the “Self-employment tax” line in

the Other Taxes section of Form 1040, page 2.

Note. The election to waive social security benefits, including

Medicare benefits, applies to all wages and self-employment income

earned before and during the effective period of this exemption and

is irrevocable for that period.

py

Reporting exempt wages. If you are a qualifying emplo

or more qualifying employees, you are not required to r

that are exempt under section 3127. Do not include the

Form 941, Employer’s Quarterly Federal Tax Return, Fo

Employer’s Annual Tax Return for Agricultural Employee

Form 944, Employer’s Annual Federal Tax Return. If you 

received an approved Form 4029, check the box on line 

941 (line 3 of Form 944) and write “Form 4029” in the e

below the check box. If you file Form 943 and have rec

approved Form 4029, write “Form 4029” to the left of th

spaces for Total wages subject to social security taxes 

wages subject to Medicare taxes.

Who may apply. You may apply for this exemption if you are a

member of, and follow the teachings of, a recognized religious group

(as defined below). If you already have approval for exemption from

self-employment taxes, you are considered to have met the

requirements for exemption from social security and Medicare taxes

and do not need to file this form.

Preparation of Form W-2. When you prepare Form W-

qualifying employee, enter “Form 4029” in the box mark

Do not make any entries in the boxes for Social security 

Medicare wages and tips, Social security tax withheld, 

tax withheld for these employees.

You are not eligible for this exemption if you received social

security benefits or payments, or if anyone else received these

benefits or payments based on your wages or self-employment

income. However, you can file Form 4029 and be considered for

approval if you paid back any benefits you received.

Recognized religious group. A recognized religious group must

meet all the following requirements:

● It is conscientiously opposed to accepting benefits of any private

or public insurance that makes payments in the event of death,

disability, old age, or retirement; makes payments for the cost of

medical care; or provides services for medical care (including social

security and Medicare benefits).

● 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. Th

of 1974 and the Paperwork Reduction Act of 1980 requ

we ask you for information we must first tell you our leg

ask for the information, why we are asking for it, and ho

used. We must also tell you what could happen if we d

it and whether your response is voluntary, required to o

benefit, or mandatory under the law.

Generally, tax returns and return information are conf

stated in section 6103. However, section 6103 allows o

Internal Revenue Service to disclose or give the informa

on your tax return to others as described in the Code. F

we may disclose your tax information to the Departmen

to enforce the tax laws, both civil and criminal, to cities

District of Columbia, U.S. commonwealths or possessio

also disclose this information to other countries under a 

federal and state agencies to enforce federal nontax cri

to federal law enforcement and intelligence agencies to 

terrorism.

Please keep this notice with your records. It may help 

ask for other information. If you have any questions abo

for filing and giving information, please call or visit any 

Revenue Service office.

The time needed to complete and file this form will v

on individual circumstances. The estimated average tim

Recordkeeping, 6 min.; Learning about the law or th

min.; Preparing the form, 15 min.; Copying, assembli

sending the form to the SSA, 16 min.

Certification. In order to complete the certification portion under

Part I, you need to enter your religious group (on the first line)

followed by the religious district or congregation (on the second line).

For example, if you enter “Old Order Amish” as your religious group,

then you would enter “Conewango Valley North District,”

“Conewango Valley West District,” etc., on the second line as the

district. However, if you are Anabaptist or Mennonite, enter the name

of your religious group as “Unaffiliated Mennonite Churches” or

“Eastern Pennsylvania Mennonite Church,” etc., and the

congregation as “Antrim Mennonite Church (Anabaptist)” or “Bethel

Mennonite Church (Mennonite),” on the second line.