SS-4 Form

Row Start

Email*

General Information

1. Legal name of entity (or individual) for whom the EIN is being requested

2. Trade name of business (if different from name on line 1)

3. Executor, administrator, trustee, “care of” name

Mailing Address

Mailing address (room, apt., suite no. and street, or P.O. box)

City, state, and ZIP code (if foreign, see instructions)

Is your street/home address different from your mailing address?

Yes
No

Street address (if different) (Don’t enter a P.O. box.)

City, state, and ZIP code (if foreign, see instructions)

6. County and state where principal business is located

7a. Name of Responsible Party

7b. SSN, ITIN, or EIN

8a. Is this application for a limited liability company (LLC) (or a foreign equivalent)?

Yes
No

8b. If 8a is “Yes,” enter the number of LLC members

8c. If 8a is “Yes,” was the LLC organized in the United States?

Yes
No

9a. Type of entity

Sole Proprietor SSN

Enter corporation form number to be filed

Specify other nonprofit organization

Specify other entity type

Social Security Number of decedent (SSN)

Plan Administrator TIN

TIN of grantor

If a corporation, name the state or foreign country (if applicable) where incorporated

9b. State

9b. Foreign Country

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10. Reason for applying

Type of Business

Specify other reason

Specify banking purpose

Specify new type of organization

Specify type of trust

Specify type of pension plan

11. Date business started or acquired (month, day, year)

12. Closing month of the accounting year

13. Highest number of employees expected in the next 12 months (enter -0- if none). If no employees expected, skip line 14.

Agricultural

Household

Other

14. Check this box if you expect your employment tax liability to be $1,000 or less in a full calendar year and want to file Form 944 annually instead of Forms 941 quarterly. If you don’t check this box, you must file Form 941 for every quarter

14. Check this box if you expect your employment tax liability to be $1,000 or less in a full calendar year and want to file Form 944 annually instead of Forms 941 quarterly. If you don’t check this box, you must file Form 941 for every quarter

15. First date wages or annuities were paid (month, day, year). Note: If applicant is a withholding agent, enter date income will first be paid to nonresident alien (month, day, year)

16. Select one box that best describes the principal activity of your business.

Specify principal activity of your business

17. Indicate principal line of merchandise sold, specific construction work done, products produced, or services provided.

18. Has the applicant entity shown on line 1 ever applied for and received an EIN?

Yes
No

Write previous Employee Identification Number (EIN):

Third Party Designee

Do you want to allow an employee, a paid tax preparer, or another person to discuss this return with the IRS?

Yes
No

Designee's Full Name

Designee's Phone Number

Designee's Fax Number

Designee's Address

Address and ZIP code

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Print your name here

Print your title here

Date

Applicant's Phone Number

Applicant's Fax Number

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SS-4

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