rm 4029 | application for Exemption From Social Security Taxes |_forsizsisi*

(Rev. April 1989) and Waiver of Benefits ‘ei ,
Department of the Treasury . . File in Triplicate
Internal Revenue Service (See instructions on back)

[Part 1 | To Be Completed by Applicant (Please print or type)

Name of taxpayer Social security number

Address (Number, street and box) City or town, state, and ZIP code

Caution: Approval of Form 4029 exempts you from social security taxes only. Generally, you are not exempt from Federal income tax.

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

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

(Way) (Monthy ‘(Weary
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.

I request that | be exempted from paying social security taxes on my earnings from self-employment under Internal Revenue Code section 1401 and from
the employer's share of social security taxes under Internal Revenue Code section 3111.

| further request exemption from the employee's share of social security taxes under Internal Revenue Code section 3101, for my services as an employee
whenever | am employed by an employer who has an identical exemption from social security taxes.

I waive all rights to any social security payment or benefit under Titles I! 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 I have never received benefits or payments under the above Titles, nor has anyone else received these
benefits based on my earnings.

l 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 the tax exemption for myself or for my employer under sections 1402(g)(1) or 3127 of the Internal Revenue Code
ceases to be effective, this waiver will also cease to be effective for:

(a) myself, with respect to all my wages and self-employment income; and

(b) my employees with respect to wages | may pay to them;
and that if my employer's exemption ceases to be effective, my exemption will cease with respect to wages paid to me by my employer. However, the waiver
will cease to be effective only to the extent that benefits and other payments under Titles II and XVIII of the Social Security Act can be payable only on the
basis of

(a) my self-employment income for and after the first tax year in which the exemption ceases to be effective; and

(b) my wages for and after the calendar year following the calendar year in which the exemption ceases to meet the requirements of section 1402(g)(1) or
3127 of the Internal Revenue Code on which the cessation of such exemption is based.

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 of Applicant >

(Watey
To Be Completed by Religious Group (Please print or type)
lcertify that___...._ 2.2222 e eee eee is a member of _____.......--2.--2 222-20 een een ne eee eee eee eee
(Name of taxpayer) (Name of religious group)
Name of Authorized Representative __________ 2. nee nn ene eee eee ere ene eee
(Piease print or type) (Address)
Signature of Authorized Representative eee eee nee eee pee eee eee eee epee eee
Citiey (Datey

For Social Security Administration Use

C1 This religious group is recognized as being in existence at all times 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.

C1 This religious group is NOT recognized as being in existence at all times 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.

(Authorized SSA representative) (ate)

For Internal Revenue Service Use
1 Approved for exemption from social security taxes. (See Caution above.)
C1 Disapproved for exemption from social security taxes.

(Director's signature) (Date)
For Paperwork Reduction Act Notice, see instructions. Form 4029 (Rev. 4-89)



Form 4029 (Rev.4-89)

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:

Recordkeeping . 7 mins
Learning about the law or the form . 12 mins
Preparing the form . . 11 mins
Copying, assembling, and id sending the

formtoSSA . . . 35 mins

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 (1545-0064), Washington, DC 20503.

General Instructions

(Section references are to the Internal Revenue Code
unless otherwise noted.)

Purpose of Form.—Form 4029 is used to apply for
exemption from social security taxes by qualifying
taxpayers.

Note: The election to waive social security benefits
including medicare is IRREVOCABLE. This exemption is for
INDIVIDUALS and does not include partnerships or
corporations.

Who May Not Apply.—You are ineligible for this
exemption if:

You received benefits or payments under Titles Il and
XVIIL of the Social Security Act, or anyone else received
these benefits or payments based on your wages or self-
employment income;

or

You do not belong to a religious group that has been in
existence at all times since December 31, 1950 and which
has provided a reasonable level of living for its dependent
members in addition to being conscientiously opposed to
participating in any program outlined in Titles II and XVIII of
the Social Security Act.

Who May Apply.—You may apply for exemption from
social security taxes if you are a member of a religious sect
or division that is recognized by the Secretary of Health and
Human Services as being 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 cost of or provides
services for, medicare (including benefits of any insurance
system established by the Social Security Act) and you
follow the teachings of your religious group.

Who Does Not Need To Apply. —If you have previously
received approval for exemption from self-employment tax
under section 1402(g), you are deemed to have met the
requirements for exemption from social security taxes
under section 3127.

When To File.—File Form 4029 when you want to apply
for exemption from social security taxes. This is a one-time
election. Keep your approved copy of Form 4029 for your
PERMANENT RECORDS.

Where To File.—Mail three copies of Form 4029 to:
Social Security Administration,

Division of Earning Eligibility and Accountability,

Metro West Building, North Block,

Baltimore, Maryland 21201,

ATTENTION: Form 4029 Process.

Use of Social! Security Number.—Enter your social
security number in the space provided. If you do not havea
social security number, file Form SS-5, Application for a
Social Security Number Card, with your Form 4029.
Effective Date of Exemption.—Exemption granted under
section 3127 begins with the first day of the first quarter,
after the quarter in which such application is filed as long
as both employer and employee continue to meet the
applicable requirements.

Signature.—Be sure to sign and date the Form 4029 on
the line for the applicant in Part | and have the
representative for your religious group sign and date the
signature line in Part Il before mailing the completed Form
4029 to the Social Security Administration.

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

Instructions to Employers

Employees without Form 4029 Approval.—lf you have
employees who do not have an approved Form 4029, you
must withhold the employee share of social security tax and
pay the employer’s share.

Reporting of 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 the

Form 943, Employer's Annual Tax Return for Agricultural
Employees. If you have received an approved Form 4029,
write the words, “Form 4029” on Form 941 on the line for
“Taxable social security wages paid” to the left of the wage
entry space. If you have received an approved Form 4029,
and you are a Form 943 filer, write the words, “Form
4029” on the line for “Taxable cash wages paid during the
year” to the left of the wage entry space.

Preparation of Form W-2.—When preparing a Form W-2
for a qualifying employee, show “Form 4029” in the box for
social security taxes withheld.