Form 14039 - Identity Theft Affidavit

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Department of the Treasury - Internal Revenue Service
OMB Number
Identity Theft Affidavit
(April 2017)
Complete this form if you need the IRS to mark an account to identify questionable activity.
Section A - Check the following boxes in this section that apply to the specific situation you are reporting
(Required for all filers)
1. I am submitting this Form 14039 for myself
2. This Form 14039 is submitted in response to a ‘Notice’ or ‘Letter’ received from the IRS
• Please provide ‘Notice’ or ‘Letter’ number(s) on the line to the right
• Please check box 1 in Section B and see special mailing and faxing instructions on reverse side of this form.
3. I am submitting this Form 14039 on behalf of my ‘dependent child or dependent relative’
• Please complete Section E on reverse side of this form.
Caution: If filing this on behalf of your ‘dependent child or dependent relative’, filing this form will protect his or her tax account
but it will not prevent the victim in Section C below from being claimed as a dependent by another person.
4. I am submitting this Form 14039 on behalf of another person (other than my dependent child or dependent relative)
• Please complete Section E on reverse side of this form.
Section B – Reason For Filing This Form
Check only ONE of the following boxes that apply to the person listed in Section C below.
1. Someone used my information to file taxes
2. I don’t know if someone used my information to file taxes, but I’m a victim of identity theft
Please provide an explanation of the identity theft issue, how you became aware of it and provide relevant dates.
If needed, please attach additional information and/or pages to this form.
Section C – Name and Contact Information of Identity Theft Victim
Victim’s last name
First name
Taxpayer Identification Number
(Please provide 9-digit Social Security Number)
Current mailing address
If deceased, please provide last known address
(apartment or suite number and street, or P.O. Box)
Current city
ZIP code
Tax Year(s) you experienced identity theft
What is the last year you filed a
(If not known, enter ‘Unknown’ in one box below)
Address used on last filed tax return
Names used on last filed tax return
(If different than ‘Current’)
(If different than ‘Current’)
ZIP code
(on last tax return filed)
Best time(s) to call
Telephone number with area code (Optional) If deceased, please indicate ‘Deceased’
Home telephone number
Cell phone number
Language in which you would like to be contacted
Section D – Penalty of Perjury Statement and Signature
Under penalty of perjury, I declare that, to the best of my knowledge and belief, the information entered on this Form 14039 is true, correct,
complete, and made in good faith.
Signature of taxpayer, or representative, conservator, parent or guardian
Date signed
Submit this completed form to either the mailing address or the FAX number provided on the reverse side of this form.
Catalog Number 52525A
(Rev. 4-2017)


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