Joint Board for the Enrollment of Actuaries                                                                        OMB Number 
    Form 5434-A 
                                                                                                                                                         1545-0951
     (November 2023)  Application for Renewal of Enrollment

    INSTRUCTIONS:  To timely renew your enrollment effective April 1, 2023, file this form on or before March 1, 2023. 
                      Also use this form to apply to return to active status from inactive status between January 1, 2023, and 
                      December 31, 2025.
All individuals enrolled before January 1, 2023, are required by 20 CFR 901.11(d) to renew their enrollment in order to maintain active 
enrollment to perform actuarial services.  
To file and pay electronically, visit www.pay.gov.  
As an alternative to filing and paying electronically, you may enclose with this form your check or money order for $680 payable to the 
Internal Revenue Service, and submit by regular mail or express delivery service to: Internal Revenue Service, Office of Enrollment, 
127 International Drive, Room EA 125, Franklin, TN 37067. 
NOTE: If you were not eligible to use the “20-” prefix to your enrollment number and are applying to return to active status pursuant to 
20 CFR 901.11(l)(7)(ii) or 20 CFR 901.11(l)(7)(iii), review the instructions posted at www.irs.gov/tax-professionals/enrolled-actuaries 
before completing or submitting this form. You may not file or pay electronically.

1. Enter the last prefix you were eligible to use and your enrollment number
Prefix                                                    Enrollment number

2. Provide the following information
Last name                                  First name                                                                              Middle name or initial

Business name (if using business address)  Address (number, street, apartment or suite)

City                                                                                State                                                       ZIP code

Daytime phone number (Include Area Code)   Email address                                                                           Check here if any information has 
                                                                                                                                   changed since the last submission

3. Follow instructions for Items A-C and check one box for Item D
A.  Enter total credit hours of qualifying professional education completed in each 
    category in the space provided.                                                                                                (Core Hours)          (Non-Core Hours)

  i.  Participant in a qualifying program, including correspondence or individual study 
      programs, audio and video recordings, and/or teleconferencing   .   .   .   .   .   .
  ii. Serving as an instructor, discussion leader, or speaker     .   .   .   .   .   .   .   .   .   .   .

  iii. Credit for published articles, books, films, audio and video recordings, etc. .   .   .   .
  iv. Service on Joint Board advisory committees or preparation of Joint Board 
      examinations  .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .  
  v. Credit earned by examination    .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .

                                                          Total Credit Hours

B.  Of the continuing professional education credit hours included in A above, enter the 
    number of continuing professional education credit hours completed in a formal 
    program described at section 901.11(f)(2)(ii) (must be at least 1/3 of total required 
    continuing professional education credit hours)   .   .   .   .   .   .   .   .   .   .   .   .   .   .   . 

C.  Of the continuing professional education credit hours included in A above, enter the 
    number of ethics credit hours completed (must be at least 2 credit hours) .   .  .  .  .  .  
                                                                                                                                                         Yes        No
D.  Did you complete all required continuing professional education credit hours by December 31, 2022

Catalog Number 63767O                                    www.irs.gov                                                               Form 5434-A (Rev. 11-2023)

                                                                                                                                  Page 2
4. Check one box for each of the following questions (see instructions)
A. Since the issuance or latest renewal of your enrollment, has an authoritative body issued a finding that you have        Yes        No
   knowingly filed or used false or misleading information or made false or misleading representations on matters 
   relating to employee benefit plans or actuarial services? If Yes, provide details on a separate page
B. Since the issuance or latest renewal of your enrollment, have you been convicted of, or fined for, any criminal          Yes        No
   offenses (including those listed in ERISA section 411) under the laws of the United States, any State or the District of 
   Columbia, or any territory or possession of the United States, which evidences fraud, dishonesty, or breach of trust?  
   If Yes, provide details on a separate page
C. Since the issuance or latest renewal of your enrollment, have you failed to timely file a required federal tax return or Yes        No
   pay a federal tax, or has an authoritative body issued a finding that you have evaded any federal tax or payment, or 
   that you have engaged in conduct described in section 901.12(f)(1)? If Yes, provide details on a separate page
D. Since the issuance or latest renewal of your enrollment, has an authoritative body issued a finding that you have        Yes        No
   failed to discharge your duties under ERISA or that you have willfully violated any of the regulations of the Joint 
   Board for the Enrollment of Actuaries? If Yes, provide details on a separate page
5. Declaration and signature
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. In addition, I declare that I have reviewed the continuing professional education requirements set forth at  
20 CFR 901.11, and to the best of my knowledge and belief, I have completed the minimum hours requirements of section 901.11(e) or 
section 901.11(l)(7), as applicable, and I have satisfied the recordkeeping requirements of section 901.11(j).
5a. Signature                                                                       5b. Date signed

                            Privacy Act and Paperwork Reduction Act Notice

Section 1242 of Title 29, United States Code, authorizes the Joint Board for the Enrollment of Actuaries (Joint Board) to collect this 
information. The primary use of the information is to enforce and administer the regulations of the Joint Board governing the practice of 
an actuary under the Employee Retirement Income Security Act of 1974 (ERISA). Information may be disclosed to: the Department of 
Justice when seeking advice or for use in any proceeding; courts and other adjudicative bodies during a proceeding; public authorities 
for their use in connection with employment, contracting, licensing, and other benefits; public authorities for their use in connection with 
their regulatory, enforcement, investigative, or prosecutorial responsibilities; contractors as necessary for performance of the contract; 
third parties as necessary during an investigation; the Department of Labor, the Department of the Treasury, and the Pension Benefit 
Guaranty Corporation for administering and enforcing ERISA or in connection with maintaining standards of integrity, conduct, and 
discipline on the part of individuals who practice before such agencies; the general public (including disclosures via web sites) for the 
purpose of publicizing or verifying the enrollment status and location of individuals who are, or were, enrolled actuaries; professional 
organizations or associations for their use in connection with maintaining standards of integrity, conduct, and discipline; appropriate 
agencies, entities, and persons when the Joint Board suspects or confirms that the security or confidentiality of information in a system 
of records has been compromised, as necessary to prevent, minimize, or remedy harm. Applying for renewal of enrollment is voluntary; 
however, providing the information requested on this form is a requirement to obtain the benefit of renewal of enrollment. Failure to 
provide the requested information could delay or prevent processing of your application. Providing false information could subject you to 
penalties. 
 
Notwithstanding any other provision of law, no person is required to respond to, nor shall any person be subject to a penalty for failure 
to comply with, a collection of information subject to the requirements of the Paperwork Reduction Act, unless that collection of 
information displays a currently valid OMB Control Number. Public reporting burden for this collection of information is estimated to 
average 30 minutes per response, including the time for reviewing the instructions, searching existing data sources, gathering and 
maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden 
estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Joint Board for the 
Enrollment of Actuaries c/o IRS/Return Preparer Office SE:RPO; Room 3422; 1111 Constitution Avenue, NW; Washington, DC 20224.

Catalog Number 63767O                                        www.irs.gov                               Form 5434-A (Rev. 11-2023)

                                                                                                                                          Page 3

            Instructions for Form 5434-A, Joint Board for the Enrollment of Actuaries  
                                   Application for Renewal of Enrollment 

General Instructions
Before completing Form 5434-A, Application for Renewal of Enrollment, review the regulations (Parts 901 and 902 of Title 20 of the 
Code of Federal Regulations). Unless otherwise indicated, section numbers (e.g., 901.12(b)) cited on the form and in the instructions 
refer to the regulations. You may download a copy of the regulations from www.irs.gov/tax-professionals/enrolled-actuaries. 
 
Do not submit Form 5434-A until you have completed the continuing professional education credit hours required for renewal of 
enrollment under section 901.11(e).

Instructions for Certain Line Items
Item 4 
The term “authoritative body” includes a court of law, a duly constituted licensing or accreditation authority, a federal or state agency, 
board, commission, hearing examiner, administrative law judge, or other official administrative authority. When responding about the 
action of an authoritative body, attach a statement specifying (as applicable) the name and address of the authoritative body, the date 
of the body's action, the nature of the finding, and the type and duration of discipline imposed. 
 
Item 4A 
See section 901.31(c)(2)-(4) for a more detailed description of the circumstances that require you to answer “Yes” to item 4A. In 
addition, under section 901.12(f)(3), an actuary may also be suspended or terminated from enrollment if the Joint Board finds that the 
actuary submitted false or misleading information on an application for enrollment to perform actuarial services or in any oral or 
written information submitted in connection therewith or in any report presenting actuarial information to any person, knowing the 
same to be false or misleading. 
 
Item 4B 
Under section 901.12(f)(2), the enrollment of an actuary may be suspended or terminated if the actuary has been convicted of any of 
the offenses (for example, robbery, bribery, extortion, embezzlement, fraud, murder, rape, perjury) referred to in section 411 of 
ERISA.  See ERISA section 411 (i.e., Section 1111 of Title 29, U.S. Code) for a more detailed list of applicable offenses. 
 
Item 4C 
Under section 901.31(c), the enrollment of an actuary may be suspended or terminated if the Joint Board finds that the actuary, 
during the period after applying for enrollment, has engaged in disreputable conduct. Answer “Yes” to item 4C if, since the issuance or 
latest renewal of your enrollment, you failed to timely file a required federal tax return or pay a federal tax for yourself, a client or 
prospective client, or an authoritative body issued a finding that you evaded any federal tax or payment for yourself, a client or 
prospective client. Also answer “Yes” to item 4C if, since the issuance or latest renewal of your enrollment, you were disbarred or 
suspended from practice as an actuary or an authoritative body issued a finding that you engaged in any of the types of conduct 
described in section 901.12(f)(1), including: 
 
 i.   Conduct evidencing fraud, dishonesty, or breach of trust. 
 ii.  Knowingly giving false or misleading information to the Department of the Treasury, Department of Labor, or the Pension 
  Benefit Guaranty Corporation.  
 iii. Attempting to influence the action of the Department of the Treasury, Department of Labor, or the Pension Benefit Guaranty 
  Corporation by coercion or inducement. 
 iv. Using abusive language, making false accusations and statements knowing them to be false, or circulating or publishing 
  malicious or libelous matter in connection with matters before the Department of the Treasury, Department of Labor, or the 
  Pension Benefit Guaranty Corporation.  
  
See section 901.12(f)(1) for a more detailed description of the circumstances that require you to answer “Yes” to item 4C. 
 
If you failed to timely file a required federal tax return or pay a federal tax, specify the type of return, the taxable period covered by the 
return, and the type and amount of any penalties imposed in your attachment to item 4C. If an authoritative body issued a finding that 
you evaded any federal tax or payment, please explain and provide a copy of the finding. Note, as part of the application process, we 
may check your federal tax history to verify that you have timely filed and paid your federal taxes. 
 
The term “disreputable conduct” is not limited to the items described above. An example of a circumstance when the Joint Board 
would investigate to determine whether an enrolled actuary’s conduct was disreputable beyond the conduct specifically listed in 
section 901.12(f)(1) is when an individual has been disciplined for cheating on an examination. Another example is when an individual 
has been disciplined for violating professional standards of an actuarial organization or other profession. 
 
Item 4D 
See sections 901.31(b) and 901.31(c)(5) for a more detailed description of the circumstances that require you to answer “Yes” to item 4D.

Catalog Number 63767O                         www.irs.gov                                                   Form 5434-A (Rev. 11-2023)