﻿Department of the Treasury -Internal Revenue Service

Form 15100
(October 2017)
Adoption Taxpayer Identification Number (ATIN) Extension Request

Complete this form, and fax or mail it to us at: 

Standard:
Internal Revenue Service
Stop 6182
Austin, TX 73301-0066
Overnight:
Internal Revenue Service
3651 S. Interregional Hwy 35
Stop 6182
Austin, TX 78741
Fax number: (855) 250-1731

If you have any questions contact us at (737) 800-5511 (not toll free)

Contact Information

Name ----
Taxpayer Identification Number ----
Name ----
Taxpayer Identification Number ----

If you changed your address, write your new address below.

Address ----
City ----
State ----
ZIP code ----
Primary telephone number ----
Best time to call ----
-- a.m.
-- p.m.
Secondary telephone number ----
Best time to call ----
-- a.m.
-- p.m.

Indicate which of the following circumstances apply to you

-- I received a social security number for ---- (Name of adoptee)
Write the social security number assigned ----
-- I need a 1 year extension for ---- (Name of adoptee)
ATIN ---- (ATIN assigned)
Reason ----
-- I couldn't get a social security number for (Name of adoptee)
ATIN ---- (ATIN assigned)
Reason ----
Status of your adoption ----
-- My adoption is final
-- My adoption is pending

I am enclosing documents the placement agency or agent signed

Original signatures of adoptive parents

Name (print/type) ----
Signature ----
Date ----
Name (print/type) ----
Signature ----
Date ----
Catalog Number 69794D
www.irs.gov
Form 15100 (Rev. 10-2017)


  