4029 OMB No. 1545-0064 Form

Application for Exemption From Social Security and

Medicare Taxes and Waiver of Benefits (Rev. November 2008)

Department of the Treasury File Three Copies Internal Revenue Service

© Before you file this form, see the instructions under Who may apply on page 2.

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)

Caution: Approval of Form 4029 exempts you from social security and Medicare taxes only. The exemption does not apply to federal

income tax. Ministers, members of religious orders, and Christian Science practitioners, see Form 4361, Application for Exemption From

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 opposed to

(Month) (Day) (Year)

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

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

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

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, for my services

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 agree that no

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-employment 

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

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 group described 

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 Revenue Code is no

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 end with respect

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 under Titles II and 

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 quarter following the calendar quarter in which the exemption no longer meets the requirements of section

1402(g)(1) or 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 and correct.

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 level of living

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 reasonable level of

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 (Rev. 11-2008)

Part I

Part II

1 Social security number

3 Date of birth

4 Contact phone number

( )

Print or type

Title © Date ©

5 Do not send me my Social Security Statement.

© Do not use prior versions of this form.

Signature of

Authorized SSA Representative ©

Signature and Title of

Authorized IRS Representative ©

Date ©

Date ©
Form 4029 (Rev. 11-2008)

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 Revenue Code

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

statement with us for any tax for which you are liable. Your response

is mandatory under these sections. Section 6109 requires that you

provide your social security number on what you file. This is so we

know who you are, and can process your return and other papers.

You must fill in all parts of the tax form that apply to you. You are

not required to provide the information requested on a form that is

subject to the Paperwork Reduction Act unless the form displays a

valid OMB control number. Books or records relating to a form or its

instructions must be retained as long as their contents may be

material in the administration of any Internal Revenue law.

Where to file. Send the original and two copies of Form 4029 to:

Social Security Administration, Security Records Center, Attn:

Religious Exemption Unit, P.O. Box 7, Boyers, PA 16020. If you are

no longer a member or no longer follow the teachings of the religious

group and your exemption is no longer effective, send a letter to

Internal Revenue Service, Ministerial Waivers Unit, DP - N837, P.O.

Box 16325, Philadelphia, PA 19114-0425.

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.socialsecurity.gov.

If you have comments concerning the accuracy of these time

estimates or suggestions for making this form simpler, we would be

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

Service, Tax Products Coordinating Committee,

SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW, IR-6526,

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

Instead, see Where to file on this page.

Effective period of exemption. An approved exemption granted to

employers and employees is effective on the first day of the first

quarter after the quarter in which Form 4029 is filed. An approved

exemption granted to self-employed individuals is effective when

granted and applies for all years for which you satisfy the

requirements. 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.

General Instructions

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.

Section references are to the Internal Revenue Code.

Purpose of form. Form 4029 is used by members of recognized

religious groups to apply for exemption from social security and

Medicare taxes. The exemption is for individuals and partnerships

(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.

Instructions to Employers

Employees without Form 4029 approval. If you have employees

who do not have an approved Form 4029, you must withhold the

employee’s share of social security and Medicare taxes and pay the

employer’s share.

Reporting exempt wages. If you are a qualifying employer with one

or more qualifying employees, you are not required to report wages

that are exempt under section 3127. Do not include these wages for

social security and Medicare tax purposes on Form 941, Employer’s

QUARTERLY Federal Tax Return, Form 943, Employer’s Annual Tax

Return for Agricultural Employees, or on Form 944, Employer’s

ANNUAL Federal Tax Return. If you have received an approved Form

4029, check the box on line 4 of Form 941 (line 3 of Form 944) and

write “Form 4029” in the empty space below the check box. If you file

Form 943 and have received an approved Form 4029, write “Form

4029” to the left of the wage entry spaces for Total wages subject to

social security taxes and Total 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

on wages and do not need to file this form.

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

qualifying employee, enter “Form 4029” in the box marked “Other.” 

Do not make any entries in the boxes for Social security wages,

Medicare wages and tips, Social security tax withheld, or Medicare

tax withheld for these employees.

Page 2

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. The Privacy Act

of 1974 and the Paperwork Reduction Act of 1980 require that when

we ask you for information we must first tell you our legal right to

ask for the information, why we are asking for it, and how it will be

used. We must also tell you what could happen if we do not receive

it and whether your response is voluntary, required to obtain a

benefit, or mandatory under the law.

Generally, tax returns and return information are confidential, as

stated in section 6103. However, section 6103 allows or requires the

Internal Revenue Service to disclose or give the information shown

on your tax return to others as described in the Code. For example,

we may disclose your tax information to the Department of Justice

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

District of Columbia, U.S. commonwealths or possessions. We may

also disclose this information to other countries under a tax treaty, to

federal and state agencies to enforce federal nontax criminal laws, or

to federal law enforcement and intelligence agencies to combat

terrorism.

Please keep this notice with your records. It may help you if we

ask for other information. If you have any questions about the rules

for filing and giving information, please call or visit any Internal

Revenue Service office.

The time needed to complete and file this form will vary depending

on individual circumstances. The estimated average time is:

Recordkeeping, 6 min.; Learning about the law or the form, 19

min.; Preparing the form, 18 min.; Copying, assembling, and

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.