Form 4029 Application for Exemption From Social Security and OMB No. 1545-0064

(Rev. April 1997) Medicare Taxes and Waiver of Benefits

Department of the Treasury File Three Copies Internal Revenue Service © See instructions on back.

To Be Completed by Applicant (Please print or type)

Name of taxpayer Social security number

Address (number, street and P.O. box) City or town, state, and ZIP code

Caution: Approval of Form 4029 exempts you from social security and Medicare taxes only. It does not apply to Federal income tax.

Before you file this form, please read the instructions under Who May Apply.

I certify that I am and continuously have been a member of

(Name of religious group)

(Religious district and location)

since , and as a follower of the established teachings of that group, I am conscientiously opposed to

(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 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 in my no longer following the established teachings of this group.

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 year following the calendar year 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 Religious Group (Please print or type)

I certify that is a member of . (Name of taxpayer) (Name of religious group)

Name of Authorized Representative

(Please print or type) (Address)

Signature of Authorized Representative ©

(Title) (Date)

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.

By

(Signature of authorized SSA representative) (Date)

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.

By

(Director’s signature) (Date)

For Paperwork Reduction Act Notice, see page 2. Cat. No. 41277T Form 4029 (Rev. 4-97)

Part I

Part II

©

© ©
Form 4029 (Rev. 4-97)

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.

The time needed to complete and file this form will vary

depending on individual circumstances. The estimated

average time is:

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

Social Security Administration

Division of Earnings Adjustments

ATTENTION: Form 4029 Process

Metro West, North Building

Baltimore, MD 21201

Recordkeeping 7 min.

Learning about the law or the form 11 min.

Preparing the form 11 min.

Copying, assembling, and sending the

form to the SSA 35 min.

Social security number.—Enter your social security

number in the space provided. If you do not have a social

security number, file Form SS-5, Application for a Social

Security Card, with your Form 4029. You can order

Form SS-5 by calling 1-800-772-1213.

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 Tax Forms Committee, Western Area

Distribution Center, Rancho Cordova, CA 95743-0001.

DO NOT send the form to this address. 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. It will last as long as both the

employer and the employee continue to meet the

requirements for exemption.

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 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 on Form 941,

Employer’s Quarterly Federal Tax Return, or on Form 943,

Employer’s Annual Tax Return for Agricultural Employees.

If you have received an approved Form 4029, write “Form

4029” on Form 941 to the left of the entry spaces on the

lines for “Taxable social security wages,” “Taxable social

security tips,” and “Taxable Medicare wages and tips.” 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 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;

make 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.

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 become material in the administration of any Internal

Revenue law. Generally, tax returns and return information

are confidential, as required by section 6103.

Paperwork Reduction Act Notice.—We ask for the

information on this form to carry out the Internal Revenue

laws of the United States. You are required to give us the

information. We need it to ensure that you are complying

with these laws and to allow us to figure and collect the

right amount of tax.