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

(Rev. January 2001) 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 or 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

(Signature of Authorized IRS Official) (Date)

For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 41277T Form 4029 (Rev. 1-2001)

Part I

Part II



 
Form 4029 (Rev. 1-2001)

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. Code 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 three copies of Form 4029 to:

Social Security Administration

Division of Earnings Adjustments

Attention: Form 4029 Process

Metro West, North Building

Baltimore, MD 21201

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. 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 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, enter

“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; 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.

Note: Do not file Form 4029 if you seek exemption for work

performed as a minister, member of a religious order, or a

Christian Science practitioner. Instead, file Form 4361,

Application for Exemption From Self-Employment Tax for Use by

Ministers, Members of Religious Orders and Christian Science

Practitioners.

Generally, tax returns and return information are confidential,

as stated in Code section 6103. However, Code 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, and certain foreign

governments to carry out their tax laws.

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, 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.