Form 3949 A - Information Referral
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1
2Department of the Treasury – Internal Revenue Service
3949 A
Form
Information Referral
OMB # 1545-1960
(2-2007)
(See instructions on reverse)
1. Taxpayer Name
2. Business Name
a. Street Address
a. Street Address
b. City/State/ZIP
b. City/State/ZIP
c. Social Security Number (SSN)
c. Employer Identification Number
d. Occupation
d. Principal Bus Activity
e. Date of Birth
3a. Name of Spouse
3. Marital Status
Married
Head of Household
Single
Divorced
Separated
4. Alleged Violation of Income Tax Law (Check all that apply).
False Exemption
Failure to Withhold Tax
Unsubstantiated Income
Unreported Income
False Deductions
Kickback
Narcotics Income
Wagering/Gambling
Multiple Filing
False/Altered Documents
Public/Political Corruption
Earned Income Credit
Organized Crime
Failure to Pay Tax
Failure to File Return
Other (Describe below)
5. Unreported Income and Tax Years (Fill in Tax Years and dollar amount(s), if known, e.g., TY2005 $10,000)
TY
$
TY
$
TY
$
TY
$
TY
$
TY
$
a. Comments (Briefly describe the facts of the alleged violation - Who/What/Where/When/How. Attach another sheet, if needed).
b. Are books/records available?
c. Do you consider the taxpayer dangerous?
Yes
No
Yes
No
d. Banks, Financial Institutions used by the taxpayer:
Name:
Name:
Address:
Address:
City/State/ZIP:
City/State/ZIP:
e. Please describe how you learned and/or obtained the information in this report (Attach another sheet, if needed):
6. Your Name:
a. Address:
b. City/State/ZIP:
c. Telephone Number (Please include the Area Code):
For Mailing Address, see Instructions
For Paperwork Reduction Act, see Instructions
3949 A
Catalog Number 47872E
Form
(Rev. 2-2007)
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