Form 14693 - Application For Reduced Rate Of Withholding On Whistleblower Award Payment Page 2
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Instructions for Application for Reduced Rate of Withholding on Whistleblower Award
Payment, Form 14693
Use this form ONLY if you have been notified that you are due to receive a whistleblower award under Section 7623(b)
and you want to reduce the rate of withholding on the award. To be considered for a reduced withholding rate, the
application (Form14693) must be received by the Whistleblower Office within 30 days from the date printed on the form.
Please read the instructions before completing the form.
Claimant
Enter the last name, first name, and middle initial of the claimant
1a.
1b.
Enter the last, first and middle initial of the claimant’s spouse, if applicable
Enter address information
1c.
Enter the last four digits of the Claimant’s Identification Number (SSN, ITIN, etc)
1d.
Enter the claim numbers
1e.
1f.
Enter the phone number
Attorney
Enter the last name, first name, and middle initial of the attorney whose fees will be deducted
2a.
Enter address information
2b.
Enter the phone number
2c.
Attorney Fees and Court Costs
Enter the dollar amount you intend to deduct on your tax return for (a) Attorney Fees and (b) Court Costs
3.
Attach Documents to Substantiate Attorney Fees and Court Costs
4a.
Agreement between claimant and attorney
Bills of attorney fees
4b.
Bills of court costs
4c.
Other documents to support attorney fees and court costs
4d.
Declaration Section
The claimant or his or her authorized representative may sign the declaration statement. This request will not be
considered complete or valid if the declaration statement is not signed with an original signature and date. If signed by an
authorized representative, provide a valid Form 2848, Power of Attorney and Declaration of Representative, with original
signatures and date.
14693
Catalog Number 67566P
Form
(2-2017)
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