. OMB No. 1545-0064
rom 4029 Application for Exemption Expires 1-31-89
(Rev, March 1986) From Tax on Self-Employment Income File in Dupli
plicate
internal Revenue Semice and Waiver of Benefits
Name of taxpayer as shown on Form 1040 Social security number
Address

City or town, state, and ZIP code

Caution: Internal Revenue Service approval of Form 4029 exempts you from self-employment tax only. Generally, as an
employee, you are not exempt from Federal income tax withholding or social security taxes.

Befere you file this form, please read instruction for Who May File.

I certify that |am and continuously have been a member Of _____ ee pce nnn ne eee eee ee etree eee
(Name of religious group)

(District and location)

and as a follower of the established teachings of that group, | am conscientiously

(Day) (Month)
opposed to accepting benefits of any private or public insurance that makes payments in the event of death, disability, old
age, or retirement or makes payments toward the cost of, or provides services for, medical care (including the benefits of
any insurance system established by the Social Security Act).

| request that | be exempted from paying self-employment tax on my earnings from self-employment, under
section 1402(g) of the Internal Revenue Code.

| waive all rights to any social security payment or benefit under Titles II and XVIII of the Social Security Act. |
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. | certify that | have never received benefits or
payments under the above Titles, nor has anyone else received these benefits based on my earnings.

| 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, | understand that if any tax exemption under section 1402(g) of the Internal Revenue Code
ceases to be effective, this waiver will also cease to be effective, but only to the extent that benefits can be payable
only on the basis of my self-employment income for and after the first tax year in which the exemption ceases to be
effective, and my wages for and after the calendar year beginning in or with the beginning of such tax year.

The first year | became subject to self-employment tax was (enter “NONE” if you were never

subject to this tax). (Wear)

Under penalties of perjury, | declare that | have examined this application and waiver and to the best of my knowledge and belief it is.
true and correct.

Signature > Date > 119
I certify that 2000.22 eee eee eee eee eee isa member of _____.__ 2-2. nn nnn e ee eee eee ee eee eee
(Name of Taxpayer) (Name of Religious Group)
Name of Authorized Representative _____.._....2---2---------o-n gece ee ce eee e eee ne ee eee eee eg ree ee eee eee eee eee
(Please print or type) (Address)
Signature of Authorized Representative... eee eee eee eee erence cece en eece een neces cence eeepep eee eee e eee
Gitiey (Date)

For Internal Revenue Service Use
© Approved for exemption from self-employment tax (see Caution above)
C_ Disapproved for exemption from self-employment tax
By.

For Paperwork Reduction Act Notice, see instructions. Form 4029 (Rev. 3-86)


Form 4029 (Rev. 3-86)

Page 2

Instructions

File two copies of this form with Internal Revenue Service
and keep one copy for your records.

Paperwork Reduction Act Notice.—We ask for this
information to carry out the Internal Revenue laws of the
United States. We need it to ensure that taxpayers are
complying with these laws and to allow us to figure and
collect the right amount of tax. You are required to give us
this information.

Who May File.—You may apply for exemption from
payment of self-employment tax if you are a member of a
recognized religious sect or division, and as a follower of
that sect’s established teachings, you are conscientiously
opposed to accepting benefits of any private or public
insurance that makes payments in the event of death,
disability, old age, or retirement, or makes payments
toward the cost of, or provides services for, medical care
(including benefits of any insurance system established by
the Social Security Act). Before you are granted an
exemption, the Secretary of Health and Human Services
must determine that: (1) the sect or division has the
established teachings referred to in the preceding
sentence; (2) it is the practice, and has been for a period of
time that the Secretary deems substantial, for members of
this sect or division to provide for their dependent members
in a manner the Secretary deems reasonable in view of the
members’ general level of living; and (3) the sect or division
has existed at all times since December 31, 1950.

Do Not File.—You are ineligible for this exemption if:

(1) You received benefits or payments under Title II or
Title XVIII of the Social Security Act, or anyone else
received these benefits or payments based on your wages
or self-employment income; or

(2) You were subject to self-employment taxes for
taxable years ending before December 31, 1967, and you
did not file this form by December 31, 1968.

When To File.—If you first become subject to self-
employment taxes for a tax year ending on or after
December 31, 1967, file this application by the due date,
including any extensions, of your income tax return for that
first tax year. If you miss this filing deadline, contact your
local internal Revenue office.

Use of Social Security Number.—Enter only your social
security number in the space provided. If you do not havea
social security number, contact your Social Security office
to apply for one. If you have applied for a social security
number, but have not received it, file Form 4029 without it
and write ‘Applied for’’ in the space for your social security
number.

Approval of Form 4029.—The filing of Form 4029 does
not automatically make you exempt from payment of
self-employment tax. You are exempt from payments of
self-employment tax only if the application is approved by
Internal Revenue Service and a copy of Form 4029 is
returned to you.

How To Indicate Exemption on Form 1040.—If the IRS
returned a copy of your application marked “approved”
write ‘Exempt Form 4029,” on the self-employment tax
line in the Other Taxes section of Form 1040.

Where To File. —Mail two copies of this form to the
Internal Revenue Service Center for the place where you

live. No street address is needed.

If you are located in:

v

Use this address:

v

Alabama, Florida, Georgia,
Mississippi, South Carolina

Atlanta, GA 31101

New Jersey, New York City and
counties of Nassau, Rockland,
Suffolk, and Westchester

Holtsville, NY 00501

New York (all other counties),
Connecticut, Maine,
Massachusetts, Minnesota, New
Hampshire, Rhode Island, Vermont

‘Andover, MA 05501

Delaware, District of Columbia,
Maryland, Pennsylvania

Philadelphia, PA 19255

Mlinors, lowa, Missourt,
Wisconsin

Kansas City, MO 64999

Kentucky, Michigan, Ohio,
West Virginia

Cincinnati, OH 45999

Kansas, Louisiana, New Mexico,
‘Oklahoma, Texas

Austin, TX 73301

Alaska, Arizona, California (counties
of Alpine, Amador, Butte, Calaveras,
Colusa, Contra Costa, Del Norte, El
Dorado, Glenn, Humboldt, Lake,
Lassen, Mann, Mendocino, Modoc,
Napa, Nevada, Placer, Plumas,
Sacramento, San Joaquin, Shasta,
Sierra, Siskiyou, Solano, Sonoma,
Sutter, Tehama, Trinity, Yolo, and
Yuba), Colorado, Idaho, Montana,
Nebraska, Nevada, North Dakota,
Oregon, South Dakota, Utah,
Washington, Wyoming,

Ogden, UT 84201

California (all other counties), Hawaii,

Fresno, CA 93888

Arkansas, Indiana, North
Carolina, Tennessee, Virginia

Memphis, TN 37501

‘American Samoa Philadelphia, PA 19255
‘Commissioner of Revenue and
Guam Taxation

Agana, GU 96910

Puerto Rico (or if excludin
income under section 933)

Virgin islands:
Nonpermanent residents

Philadelphia, PA 19255

Virgin Islands:
Permanent residents

V.I. Bureau of Internal Revenue,
P.O. Box 3186
St. Thomas, VI 00801

Foreign country:
US. citizens and those filing Form
2555 or Form 4563, even if you have
anA.P.0. or F-P.O. address

Philadelphia, PA 19255

AP.O. or F.P.O. address of:

Miami—Atlanta, GA 31101

New York—Holtsville, NY 00501
San Francisco—Fresno, CA 93888
Seattle—Ogden, UT 84201

U.S, Government Printing Office: 1987-201.993/60110