Fillable Form 3949-A Information Referral (Page 3 of 3) in pdf

Page 3

Kickback- Received illegal payments or kickbacks in exchange for referring the business of a government agency or other

business towards a company or for influencing business decisions that result in part of the payment for the business

received or service performed being returned to the person who made the referral.

Wagering/Gambling- Did not report income received from wagering or gambling.

Failure to Withhold Tax- Individual or business did not withhold legally owed taxes from income paid to their employee(s),

such as Social Security or Medicare taxes. Example: A business treated employees as independent contractors and

issued Forms 1099, with no tax withheld, instead of a W-2.

Failure to File Return- Individual or business has not filed returns legally due.

Failure to Pay Tax- Individual or business has not paid taxes legally due.

Other- Describe in 5.

4. If your report involves unreported income, indicate the year(s) and the dollar amount(s).

5. Briefly describe the facts of the alleged tax law violation(s) as you know them. Please attach another sheet, if you

need more room.

6. Additional Information, if known. Attach another sheet, if you need more room.

Section C – Provide Information about Yourself

7. Note: Information about yourself is NOT required to process your report, but may be helpful if we need additional

information.

Please print and send your completed form to the Internal Revenue Service at:

Internal Revenue Service

Stop 31313

Fresno, CA 93888

Paperwork Reduction Notice

We ask for the information on this form to carry out the Internal Revenue laws of the United States. This report is voluntary and the information requested helps us

determine if there has been a violation of Income Tax Law. We need it to insure that taxpayers are complying with these laws and to allow us to figure and collect

the right amount of tax.

You are not required to provide the information on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number.

Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administrations of any Internal

Revenue laws. Generally, tax returns and tax return information are confidential, as required by Code section 6103.

The time required to complete this form will vary depending on individual circumstances. The estimated average time is 15 minutes.

Privacy Act Notice

We are requesting this information under authority of 26 U.S.C. 7801. The primary purpose of this form is to report potential violations of the Internal Revenue

laws. The information may be disclosed to the Department of Justice to enforce the tax laws. Providing the information is voluntary. Not providing all or part of the

information will not affect you.

3949-A

Catalog Number 47872E

Form

(Rev. 4-2016)

Form 3949-A Information Referral Page 3

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