1/4 Personal Information

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

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

3. Executor, administrator, trustee, "care of" name i

Mailing Address

Country

Address i

Apt/Ste No

City

State

Zip Code

Is your street/home address different from your mailing address? Yes No

Country

Address i

Apt/Ste No

City

State

Zip Code

6. County and state where principal business is located * i

7a. Name of Responsible Party * i

7b. SSN, ITIN, or EIN i

8a. Is this application for a limited liability company (LLC) or a foreign equivalent? Yes No

9a. Type of entity * i

Enter corporation form number i

Name the state or foreign country (if applicable) where incorporated

9b. State

9b. Foreign Country

10. Reason for applying * i

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

12. Closing month of the accounting year i

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

Agricultural * i

Household * i

Other * i

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) i

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

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

18. Has the applicant entity shown on line 1 ever applied for and received an EIN? Yes No

SS4 Form

1/4 Personal Information

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Third Party Designee

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