Form SS-4
(Rev. December 2019)
Department of the Treasury
Internal Revenue Service

Application for Employer Identification Number

(For use by employers, corporations, partnerships, trusts, estates, churches,
government agencies, Indian tribal entities, certain individuals, and others.)
Go to www.irs.gov/FormSS4 for instructions and the latest information.
See separate instructions for each line. Keep a copy for your records.

OMB No. 1545-0003

EIN
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
4a Mailing address (room, apt., suite no. and street, or P.O. box 5a Street address (if different) (Don’t enter a P.O. box.)
4b City, state, and ZIP code (if foreign, see instructions) 5b 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)? . . . . . . . . 		8b   If 8a is “Yes,” enter the number of
LLC members . . . . . .
8c   If 8a is “Yes,” was the LLC organized in the United States? . . . . . . . . . . . . . . . . . .
9a   Type of entity (check only one box). Caution: If 8a is “Yes,” see the instructions for the correct box to check.






Group Exemption Number (GEN) if any
9b   If a corporation, name the state or foreign country (if
applicable) where incorporated 		State Foreign Country
10   Reason for applying (check only one box)

11   Date business started or acquired (month, day, year). See instructions.
12   Closing month of 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    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, check here. (Your employment tax liability generally will be $1,000< or less if you expect to pay $5,000 or less in total wages.)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   Check one box that best describes the 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?
If “Yes,” write previous EIN here
Third Party Designee
 Complete this section only if you want to authorize the named individual to receive the entity’s EIN and answer questions about the completion of this form.
Designee’s name Designee’s telephone number (include area code)
Address and ZIP code Designee’s fax number (include area code)
Under penalties of perjury, I declare that I have examined this application, and to the best of my knowledge and belief, it is true, correct, and complete Name and title (type or print clearly) Applicant’s telephone number (include area code)
Date : 04-May-2024
Applicant’s fax number (include area code)
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 16055N      Form SS-4 (Rev. 12-2019