Form SSA-1458 Certification by Religious Group

Form SSA-1458 (01-2019) UF
Discontinue Prior Editions
Social Security Administration

CERTIFICATION BY RELIGIOUS GROUP

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OMB No. 0960-0093

(Regarding tenets or teachings on acceptance of insurance benefits and provision for dependent members)
Full Name and Mailing Address of Religious Group

Print Your Name (First name, middle initial, last name)

I am the
and a duly appointed and authorized spokesman for the
(Title)
religious group named above and certify the following information regarding this religious group:
1. Do the established tenets or teachings of this religious group oppose the acceptance of benefits of any
private or public insurance which makes payments in the event of death, disability, old-age, or retirement
or makes payments toward the cost of, or provides services for, medical care, including the benefits of
any insurance system established by the Social Security Act?
If "Yes," submit documents, statements, or other writings to support your answer.
Yes
No
2. Is it the practice of this religious group to make provision for their dependent members?
If "Yes," briefly describe how dependent members are provided for and submit documents,
statements, or other writings to support your answer.
Yes

No

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3. (a) Has this religious group been in existence at all times since December 31, 1950?
Yes
No
DATE ESTABLISHED (if unknown, so indicate)
(b) Enter the date this religious group was established.
Submit any available documents, writings, or other evidence to support your answers to (a) and (b) above.

Form SSA-1458 (01-2019)
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Answer 4 only if this religious group was established after December 31, 1950.
4. (a) Is this religious group a division or offshoot of another religious group with similar tenets and
teachings?
Yes
No
If "Yes," answer (b), (c), and (d) below. If "No," go on to item 5.
(b) Enter the full name of the group of which this group is a division or offshoot.
(c) Enter the date the religious group in (b) above was
established

DATE ESTABLISHED (if unknown, so indicate)

(d) Are the tenets, teachings and practices of the religious group in (b) above identical to those described
in items 1 and 2 above?
Yes
No
If "No," explain the differences.
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5. Have the tenets, teachings and practices of this religious group (and, if applicable, the group of which it is
a division or offshoot) been the same as shown in items 1, 2, and 4 above at all times since December
31, 1950, or if later, the date the religious group was established?
If "No," explain any changes and indicate when changes took place.

Yes

No

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6. I understand that it is the obligation of the group spokesman to notify the Social Security Administration in
the event there is any change in the tenets, teachings and practices of this religious group as indicated
above.

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Form SSA-1458 (01-2019)

Privacy Act Statement
Collection and Use of Personal Information

Section 211(c)(6) of the Social Security Act, as amended, allows us to collect this information. Furnishing us
this information is voluntary. However, failing to provide all or part of the information may prevent an
accurate and timely decision on the tax exemption eligibility for the religious group.
We will use the information to verify that members meet or continue to meet the criteria for exemption. We
may also share your information for the following purposes, called routine uses:
• To officers and employees of Federal, State or local agencies upon written request in accordance with
the Internal Revenue Code (IRC) U.S.C. 6103(1)(7)), tax return information (e.g., information with
respect to net earnings from self-employment, wages, payments of retirement income which have
been disclosed to the Social Security Administration, and business and employment addresses) for
purposes of, and to the extent necessary in, determining an individual's eligibility for, or the correct
amount of, benefits under certain programs listed in the IRC; and
• To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social
Security Administration (SSA) in the efficient administration of its programs. In addition, we may share
this information in accordance with the Privacy Act and other Federal laws. For example, where
authorized, we may use and disclose this information in computer matching programs, in which our
records are compared with other records to establish or verify a person’ eligibility for Federal benefit
programs and for repayment of incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice (SORN) 60-00059,
entitled Earnings Recording and Self-Employment Income System as published in the Federal Register
(FR) on January 11, 2006, at 71 FR 1819. Additional information and a full listing of all our SORNs is
available on our website at https://www.ssa.gov/privacy.

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. §
3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these
questions unless we display a valid Office of Management and Budget (OMB) control number. We estimate
that it will take about 15 minutes to read the instructions, gather the facts, and answer the questions. Send
only comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD
21235-6401.
SIGNATURE

TITLE

DATE