SPECIFIC

Where To File.

If you are located in:

Internal Revenue Service Center
11601 Roosevelt Boulevard
Philadelphia, Pa. 19155

Internal Revenue Service Center
1040 Waverly Avenue
Holtsville, N.Y. 1179:

~~“Internal Revenue Service Center
4800 Buford Highway
Chamblee, Georgia 30006
Internal Revenue Service Center
Cincinnati, Ohio 45298
Infernal Revenue Service Center
51 S. Interregional Highway
_ Austin, Texas 78740
Alaska, Arizona, Colorado, Idaho, Internal Revenue Service Center
Minnesota, Montana, Nebraska, 1160 West 1200 South Street
Nevada, North Dakota, Oregon, Ogden, Utah 84405
South Dakota, Utah, Washington,
Wyoming _
Iilinois, lowa, Missouri, Wisconsin

Delaware, District of Columbia,
Maryland, Pennsylvania

New Jersey

Alabama, Florida, Georgia, Missis-
sippi, South Carolina

Michigan, Oho

Arkansas, Kansas, Louisiana, New
Mexico, Oklahoma, Texas.

Internal Revenue Service Center
2306 E. Bannister Roa

Kansas City, Mo. 64170
Internal Revenue Service Center
310 Lowell Street

Andover, Mass. 01812
Internal Revenue Service Center
3131 Democrat Road

Memphis, Tenn. 38110

Connecticut, Maine, Massachusetts, —

New Hampshire, New York, Rhode
Vermont

inaiana,, Kentucky, North Carolina,

Tennessee, Virginia, West Virginia

INSTRUCTIONS

California, Hawaii Internal Revenue Service Center
5045 East Butler Avenue

Fresno, California 93730

If you have no legal residence in the United States then mail
this form to the Internal Revenue Service Center, 11601 Roose-
veit Boulevard, Philadelphia, Pennsylvania 19155.

Item 1.—Enter your social security number as it appears on
your social security card. If you have no number, file application
Form SS$-5 with the local office of the Social Security Adminis-
tration. If you do not receive your card in time, file Form 4361
and enter “Applied for” in the space provided for the number.

Item 3.—Enter the date you were duly ordained, commis
sioned, or licensed as a minister of a church, or date you became
a member of a religious order, or date you commenced practice
as a Christian Science practitioner. No application for exemption
should be filed prior to such date.

Item 4.—If you are a minister or a member of a religious
order, enter the name of the church denomination which or-
dained, commissioned, or licensed you or the order of which you
are now a member.

Item 6.—Sign your name and enter the date. Do not print
unless that is your usual way of signing.

Item 7.—Enter your name and mailing address. If you get
your mail in a city, enter the number and name of the street and
ZIP code; if in the country, the R.D. route, box number and ZIP
code; if at the post office, the P.O. box number and ZIP code.

‘i US. GOVERNMENT PRINTING OFFICE: 1972—0-471-124-E1, 10705,


Form 4361 Application for Exemption From Self-Employment Tax for Use by

(Rev. July 1972) Ministers, Members of Religious Orders and Christian Science Practitioners
Department of the Treasury . .
Internal Revenue Service (Before filing this form see General Instruction B)
1. Social security number 2. Check () Ordained Minister, Priest, Rabbi (2 Commissioned or Licensed Minister | 3. Date ordained, licensed, etc.
: ' applicable (See General Instruction B)
H H box: ( Member of Religious Order (0 Christian Science Practitioner

4. Name of Denomination or Religious Order | 5. Enter the first two years after 1954 in which you had net earnings from self-employ-
ment of $400 or more, some part of which was from services as a minister, priest,

rabbi, etc.; or as a member of a religious order; or as a Christian Science practitioner

19

6. | certify that | am conscientiously opposed to, or because of religious principles opposed to, the acceptance (with respect to services performed by me
as a minister, member, or practitioner) of any public insurance which 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).

| certify that | did not file an effective waiver certificate (Form 2031) electing social security coverage on earnings as a minister, member, or practitioner.

I hereby request an exemption from payment of self-employment tax with respect to my earnings from services as a minister, member, or practitioner,
pursuant to the provisions of section 1402(e) of the Internal Revenue Code.

Under penalties of perjury, | declare that this application has been examined by me and to the best of my knowledge and belief it 1s true and correct.

19

Signature Date _.

For Internal Revenue Service Use | 7. Name, address, and ZIP code (Please print or type)
LO Approved for exemption

19

( Disapproved for exemption

by

Director's signature Date

File in triplicate with Internal Revenue Service Copy A—To be retained by Internal Revenue Service


General Instructions
Once an exemption has become effective, it is irrevocable, and Form 4361 should not be filed for any subsequent year.

A. Purpose of This Form.—For taxable years ending before
1968, services performed by duly ordained, commissioned, or
licensed ministers of churches, members of religious orders (who
had not taken a vow of poverty) and Christian Science prac-
titioners were not covered under the Federal social security pro-
gram unless the individual filed a Form 2031 (Waiver Certificate
To Elect Social Security Coverage For Use By Ministers, Certain
Members Of Religious Orders, and Christian Science Practi-
tioners). For taxable years ending after 1967, however, the Social
Security Amendments of 1967 provide that such services are
covered unless the minister, member of a religious order, or
practitioner requests exemption from social security coverage.
I¥ an individual desires to apply for exemption, this form should

ve used,

B. Who May File for Exemption.—Any duly ordained, com-
missioned, or licensed minister of a church, member of a re-
ligious order (who has not taken the vow of poverty), or Christian
Science practitioner may file for exemption from self-employ-
ment tax. The request for exemption must be based on his op-
position, because of conscience or religious principles, to the

acceptance (with respect to services performed by him as a
minister, member, or practitioner) of public insurance (including
social security benefits) which makes payments in the event of
death, disability, old-age, or retirement or makes payments to-
ward the cost of, or provides services for, medical care. However,
if the minister, member, or practitioner has previously filed an
effective waiver certificate Form 2031, he may NOT now file for
an exemption.

If you are a member of a religious order and have taken a
vow of poverty, you are exempt from self-employment tax and
need not file this form.

Commissioned or licensed ministers of a church or church
denomination which provides for ordination of ministers may
file an application for exemption only if they are invested with
the authority to perform all of the ecclesiastical duties of their
church or church denomination.

If you have any question about your eligibility for exemption,

consult an Internal Revenue office.
(Continued on back of Copy C)

Ye U,S. GOVERNMENT PRINTING OFFICE: 1972—0-471-124-E.. 10705


Forn 4361 Application for Exemption From Self-Employment Tax for Use by

box: 1s Order Ci Christian Science Practitioner

(Rev. July 1972) Ministers, Members of Religious Orders and Christian Science Practitioners

Department of the Treasury aa " a

Internal Revenue Service (Before filing this form see General Instruction B)

1, Social security number 2. Check © Ordained Minister, Priest, Rabbi (1 Commissioned or Licensed Minister | 3. Date ordained, licensed, ete.
applicable (See General Instruction B) |

Member of Religi

5. Enter the first two years after 1954 1n which you had net earnings from self-employ-
ment of $400 or more, some part of which was from services as a minister, priest, |
abbI, eter oF as a mernber of 2 religious order; or asa Christian Science practitioner | 19

4. Name of Denomination or Religious Order

| 19

6. | certify that | am conscientiously opposed to, or because of religious principles opposed to, the acceptance (with respect to services performed by me
as a minister, member, or practitioner) of any public insurance which 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).
I certify that | did not file an effective waiver certificate (Form 2031) electing social security coverage on earnings as a minister, member, or practitioner.
| hereby request an exemption from payment of self-employment tax with respect to my earnings from services as a minister, member, or practitioner,
pursuant to the provisions of section 1402(e) of the Internal Revenue Code.
Under penalties of perjury, | declare that this application has been examined by me and to the best of my knowledge and belief it 1s true and correct.

Date -. 19

Signature

For Internal Revenue Service Use 7. Name, address, and ZIP code (Please print or type)
1 Approved for exemption
1 Disapproved for exemption

by _

Director's signature Date
File in triplicate with Internal Revenue Service Copy B—To be forwarded to Social Security