. . OMB No. 1545-0064
rom 4029 Application for Exemption Expires 12-31-91 _
Neuiinanal From Tax on Self-Employment Income File in Duplicate
Internal Revenue Service 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.

Before you file this form, please read the instructions under Who May Apply.
| certify that | am and continuously have been a member of o_o... nnn etn nee eeng ee eee eee eee eee

(District and location)

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

(Day) (Month) (Year)
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. Public insurance includes
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 > ,19

I certify that isa member of __________..-.-------.-------22---2e-ee-n een e eee een

(Name of taxpayer) (Name of religious group)

Name of Authorized Representative

Signature of Authorized Representative

Gitley (Date)

For Internal Revenue Service Use
C1 Approved for exemption from self-employment tax (see Caution above)
(1 Disapproved for exemption from self-employment tax

For Paperwork Reduction Act Notice, see instructions. Form 4029 (Rev. 12-88)


Form 4029 (Rev.12-88)

Page 2

General Instructions
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.

The time needed to complete and file this form will vary
depending on individual circumstances. The estimated
average times are:

Learning about the

lawortheform. . . . . . 2... . . . 7min.
Preparing the form . 13 min.
Copying, assembling,
and sending the form
toIRS ... . 35min.

If you have comments concerning the accuracy of these
time estimates or suggestions for making this form more
simple, we would be happy to hear from you. You can write
to the Internal Revenue Service, Washington, DC 20224,
Attention: IRS Reports Clearance Officer, TR:FP; or the
Office of Management and Budget, Paperwork Reduction
Project, Washington, DC 20503.

Purpose of Form.— File Form 4029 at any time you wish
to apply for exemption from paying self-employment tax.

Who May Apply. ‘ou must be a member of a recognized
religious sect or division. As a follower of that sect’s or
division's established teachings, you must be
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 costs of, or provides services for,
medical care. Public insurance includes benefits of any
insurance system set up by the Social Security Act. If
approved, a copy of your Form 4029 will be returned to you
marked “Approved.”

Who May Not Apply.—Do not file Form 4029 if 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.

Approval of Application. —Filing Form 4029 does not, by
itself, exempt you from paying self-employment tax. You
are exempt only if IRS returns a copy of Form 4029 to you
marked “Approved.” Before your application can be
approved, the Secretary of Health and Human Services
must determine that: (1) your sect or division has
established teachings that conform with conditions given
under “Who May Apply,” above; (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.

Indicating Exemption on Form 1040.—If IRS returned a
copy of your Form 4029 marked “Approved,” write
“Exempt Form 4029” on the self-employment tax line in
the Other Taxes section of Form 1040.

Specific Instructions

File two copies of this form with IRS and keep one copy for
your records.

Enter only your social security number in the space
provided. If you do not have a number, file Form SS-5 with
your local Social Security Administration office. If you do
not receive your card in time, file Form 4029 and enter
“Applied for” in the space for the number.

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:

Use this address:

v v
Florida, Georgia,
South Carolina Atlanta, GA 39901

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

Holtsville, NY 00501

Connecticut, Maine,
Massachusetts, New Hampshire,
Rhode Island, Vermont,

New York (all other counties)

Andover, MA 05501

Delaware, District of Columbia,
Maryland, Pennsylvania, Virginia

Philadelphia, PA 19255

Illinois, lowa, Minnesota, Missoun,
Wisconsin

Kansas City, MO 64999

Indiana, Kentucky, Michigan,
‘Ohio, West Virginia

Cincinnati, OH 45999

Kansas, 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, Marin, 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

Alabama, Arkansas, Louisiana, Mississippi,
North Carolina, Tennessee

Memphis, TN 37501

American Samoa

Philadelphia, PA 19255

Guam

Commissioner of Revenue
and Taxation

855 West Marine Drive
‘Agana, GU 96910

Puerto Rico (or if excluding
income under section 933)

Virgin Islands:
Nonpermanent residents

Philadelphia, PA 19255

Virgin Islands:
Permanent residents

V.1. Bureau of Internal Revenue
Lockharts Garden No. 1A
Charlotte Amalie

St. Thomas, VI 00802

Foreign country:
U.S. citizens and those filing Form
2555 or Form 4563, even if you have
an A.P.O. or F.P.O. address

Philadelphia, PA 19255

A.P.O. or F.P.O. address of

Miami—atlanta, GA 39901

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