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OMB No. 1545-00644029Form Application for Exemption From Social Security andMedicare Taxes and Waiver of Benefits(Rev. J anua ry 2001)

File Three CopiesDepa rtment of the Treas uryInternal Revenue Service

See instructions on back.

To Be Completed by Applicant (Please print or type)

Name of taxpayer Social security number

City or town, state, and ZIP codeAddress (number, street or P.O. b ox)

Caution:App roval of Form 4029 exempts you from social security and Medicare taxesonly. It does not app ly 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 , a nd as a follower of the es tablished tea chings of that g roup, I am co nscientiously opposed to(Day)(Month) (Year)

ac cepting benefits o f any private or public insurance that ma kes payments in the event o f dea th, disability, old a ge, or retirement; or makes payments forthe cos t of med ica l care; or provides services for medica l care. P ublic insurance includes any insurance system esta blished by the So cial Security Act.

I request that I be exempted from paying social security and Medicare taxes on my earnings from self-employment under Internal RevenueCod e s ection 1401 and from the employers s hare of s ocial security and Medica re taxes under Internal Revenue Cod e s ection 3111.

I further request exemption from the employees share of social security and Medicare taxes under Internal Revenue Code section 3101, for

my services as an employee w henever I am employed by a n employer who has an identica l exemption from soc ial security and Medica re taxes.I waive al l r ights to any social secur ity paym ent or benef i t und er Tit les II and XVIII of th e Social Secur i ty Act. I understand and agree

that no benef i ts or other paym ents of any kind under Tit les II and XVIII of the Social Secur ity Act wi l l be paid based on m y w ages and

self-employment incom e to any oth er person. I cert i fy that I have never received benef i ts or payments und er the above t i t les, nor has

anyone else received these benef i ts based on m y 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 religiousgroup 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 RevenueCode is no longer effective, this waiver will also no longer be effective for:

myself, w ith respect to all my wag es and self-employment income; a nd

my employees with respect to wages I may pay to them; and that if my employers exemption is no longer in effect, my exemption will endwith respect to wages paid to me by my employer. However, the waiver will no longer be effective only to the extent that benefits and otherpaym ents und er Titles II and XVIII of the So cial Sec urity Act c an b e pa yab le on the ba sis of:

my self-employment income for and after the first tax year in which the exemption ends; and

my w ag es for and a fter the ca lendar yea r following the c alendar year in which the exemption no longer meets the requirements o f sec tion1402(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)

is a member of .I certify tha t(Name of religious group)(Name of taxpayer)

Name of Authorized Representative(Address)(P lease print or type)

Signa ture o f Authorized Representa tive

(Date)(Title )

Social Security Administration Use Only

This religious group is reco gnized as being in existence co ntinuously s ince Dec ember 31, 1950, as providing a rea sona blelevel of living for its dependent members, and as being conscientiously opposed to public or private insurance.

This re lig ious g roup is not recognized as being in existence continuously since December 31, 1950, as providing a reasonablelevel of living for its d epe ndent me mbe rs, and /or as b eing co nsc ientiously oppos ed to public o r private insuranc e.

By(Date)(Signature of authorized SSA representative)

Internal Revenue Service Use OnlyApproved for exemption from social security and Medicare taxes. (See Caution in Part I above.)

Disa pproved for exemption from so cial sec urity a nd Medicare taxes .

By(Date)(Signature of Authorized IRS Official)

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

Part I

Part II

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Form 4029 (Rev. 1-2001)

When to file. File Form 4029 when you want to apply forexemption from s ocial se curity a nd Medica re taxes . This is aone-time election. Keep your approved copy of Form 4029 foryour permanent records.

Our authority to ask for information is Internal Revenue Codesections 6001, 6011, and 6012(a) which require you to file areturn or statement with us for any tax for which you are liable.Your response is mandatory under these sections. Code section6109 requires that you provide your social security number onwha t you file. This is so we know who you a re, and c an proces syour return and other papers. You must fill in all parts of the taxform that apply to you. You are not required to provide theinformation requested on a form that is subject to the Paperwork

Reduction Act unless the form displays a valid OMB controlnumber. Books or records relating to a form or its instructionsmust be retained as long as their contents may be material inthe administration of any Internal Revenue law.

Where to file. Send three copies of Form 4029 to:Social Security AdministrationDivision of Earnings AdjustmentsAttention: Form 4029 Proc es sMetro West, North BuildingBaltimore, MD 21201

Social security number. Enter your soc ial s ecurity numbe r inthe space provided. If you do not have a social security number,file Form SS-5, Application for a Social Security Card, with yourForm 4029. You can order Form SS-5 by calling1-800-772-1213.

If you have c omments c oncerning the a ccuracy of these timeestimates or suggestions for making this form simpler, we wouldbe ha ppy to hea r from you. You ca n write to the Ta x FormsCommittee, 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 onthe first day of the first quarter after the quarter in which Form4029 is filed. The exe mption w ill continue a s long a s y ou, o r inthe case of wage payments, both the employee and employer,continue to meet the exemption requirements.

General Instructions

Signature. The co mpleted Form 4029 must be signed and da tedby the applicant in Part I and by the authorized representative ofthe religious group in Part II.

Section references are to the Internal Revenue Code.

Purpose of form. Form 4029 is used by members of recognizedreligious groups to apply for exemption from social security andMedicare ta xes. The e xemption is for individua ls andpartnerships (when all the partners have approved certification).

How to show exemption from self-employment taxes onForm 1040. If the IRS returned your copy of Form 4029 markedApproved, write Form 4029 o n the Self-employment taxline in the Other Taxes section of Form 1040, page 2.

Note: The election to waive social security benefits, includingMed icare benefits, applies to all wages and self-emp loyment

income earned before and during the effective period of thisexemption and isi r revocablefor that period.

Instructions to EmployersEmployees without Form 4029 approval. If you haveemployees who d o not ha ve an a pproved Form 4029, you mustwithhold the employee s sha re of social security and Medica retaxes and pay the employers share.

Reporting exempt wages. If you are a qualifying employer withone or more qualifying employees, you are not required to reportwages that are exempt under section 3127. Do not include thesewages on Form 941, Employers Qua rterly Fed era l Ta x Return,or on Form 943, Employers Annua l Ta x Re turn for AgriculturalEmployees. If you have received an approved Form 4029, enterForm 4029 on Form 941 to the left of the entry spa ces on thelines for Ta xab le s ocial sec urity w ag es , Ta xab le s oc ial se curitytips, a nd Ta xab le Medicare w a ges a nd tips. If you file Form 943and have received an approved Form 4029, write Form 4029to the left of the wag e entry spa ces for Total wa ges subject tosoc ial sec urity taxes and Total wa ges subject to Medica re taxes.

Who may apply. You may apply for this exemption if you are amember of, and follow the teachings of, a recognized religiousgroup (as defined below). If you already have approval forexemption from self-employment taxes, you are considered tohave met the requirements for exemption from social securityand Medica re ta xes a nd do not need to file this form.

Preparation of Form W-2. When you prepare Form W-2 for aqualifying employee, enter Form 4029 in the box markedOther. Do not make a ny entries in the boxes for Social securitywages, Medicare wages and tips, Social security tax withheld, orMedicare tax withheld for these employees.

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You are not eligible for this exemption if you received socialsecurity benefits or payments, or if anyone else received thesebenefits or pa yments ba sed on your wag es or self-employmentincome. However, you can file Form 4029 and be considered forapproval if you paid back any benefits you received.

Recognized religious group. A recog nized religious g roup mustmeet all the fo llow ing requirements :

It is cons cientiously oppos ed to a ccepting benefits o f anyprivate or public insurance that makes payments in the event ofdeath, disability, old age, or retirement; makes payments for thecost of medical care; or provides services for medical care(including so cial se curity a nd Medicare b enefits).

It has provided a reasonable level of living for its dependentmembers.

It has existed continuously since December 31, 1950.

Privacy Act and Paperwork Reduction Act Notice. The P rivac y

Act of 1974 and the Paperwork Reduction Act of 1980 requirethat when we ask you for information we must first tell you ourlegal right to ask for the information, why we are asking for it,and how it will be used. We must also tell you what couldhappen if we do not receive it and whether your response isvoluntary, required to obtain a benefit, or mandatory under thelaw.

Note: Do notfile Form 4029 if you seek exemption for workperformed as a minister, memb er of a religious order, or a

Christian Science p ractitioner. Instead, fileForm 4361,App lication 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 sta ted in Code sec tion 6103. However, Co de s ection 6103allows or requires the Internal Revenue Service to disclose orgive the information shown on your tax return to others asdesc ribed in the Cod e. For example, we ma y disclose your taxinformation to the Depa rtment of J ustice to enforce the tax law s,both civil and criminal, to cities, states, the District of Columbia,U.S. commonwealths or possessions, and certain foreigngovernments to carry out their tax laws.

Please keep this notice with your records. It may help you ifwe ask for other information. If you have any questions about

the rules for filing and giving information, please call or visit anyInternal Revenue S ervice office.

The time need ed to co mplete a nd file this form will va rydepe nding on individua l circums tanc es . The estimate d a veragetime is: Recordkeeping, 7 min.; Learning about the law or theform, 11 min.; Preparing the form, 11 min.; Copying,assembling, and sending the form to the SSA, 35 min.