Form 4029 (2008) - Application For Exemption From Social Security And Medicare Taxes And Waiver Of Benefits

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4029

Application for Exemption From Social Security and

OMB No. 1545-0064

Form

Medicare Taxes and Waiver of Benefits

(Rev. November 2008)

Before you file this form, see the instructions under Who may apply on page 2.

File Three Copies

Department of the Treasury

Internal Revenue Service

Do not use prior versions of this form.

Caution: Approval of Form 4029 exempts you from social security and Medicare taxes only. The exemption does not apply to federal

income tax. Ministers, members of religious orders, and Christian Science practitioners, see Form 4361, Application for Exemption From

Self-Employment Tax for use by Ministers, Members of Religious Orders, and Christian Science Practitioners.

To Be Completed by Applicant (Print or type)

Part I

Name of taxpayer

Social security number

Address (number, street, or P.O. box)

Date of birth

City or town, state, and ZIP code

4 Contact phone number

(

)

Do not send me my Social Security Statement.

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

(Name of religious group)

(Religious district or congregation, and county and/or city, state, and ZIP code)

since

, and as a follower of the established teachings of that group, I am conscientiously opposed to

(Month)

(Day)

(Year)

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 no longer following the established teachings of this group. See Where to file on page 2.

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 quarter following the calendar quarter 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 Authorized Representative of Religious Group (Print or type)

Part II

I certify that

is a member of

(Name of taxpayer)

(Name of religious group/district/congregation)

Name of Authorized Representative

(Please print or type)

(Address)

Signature of