Form 14457 - Offshore Voluntary Disclosure Letter
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1
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3Department of the Treasury–Internal Revenue Service
14457
OMB Number
Form
Offshore Voluntary Disclosure Letter
1545-2241
(November 2017)
If taxpayer has domestic issues only, please have them apply for a traditional voluntary disclosure.
Submit Form 14457 to: Internal Revenue Service
Voluntary Disclosure Coordinator
1-D04-100
2970 Market Street
Philadelphia, PA 19104
To assist in a timely determination of acceptance into the Voluntary Disclosure Program (for Voluntary Disclosures involving offshore
accounts), the Taxpayer must address all of the following items. All answers and attachments must be in English.
If you filed jointly at any point during the past eight years, your spouse should also apply for the OVDP by answering the
questions below.
Date
1a. Name
1b. Taxpayer Identification Number
1c. Date of Birth
Taxpayer
Taxpayer
Taxpayer
Spouse
Spouse
Spouse
1d. Address
1e. Telephone number
Taxpayer
Taxpayer
Spouse
Spouse
For items 1f through 1k, attach additional sheets, if necessary.
1f. Passport Number(s)
1g. Country(ies)
1h. Current Occupation
Taxpayer
Taxpayer
Taxpayer
Spouse
Spouse
Spouse
1i. Bank Name(s)
1j. Name on Bank Account
1k. Bank Account Number(s)
Taxpayer
Taxpayer
Taxpayer
Spouse
Spouse
Spouse
Note: Estates must include a court document or Form 56 verifying who is authorized to sign the Form 2848.
2a. Taxpayer Representative
2b. Phone Number
2c. Address of Taxpayer Representative
2d. Email address of Taxpayer Representative
3. Type of Voluntary Disclosure
Offshore Only
Offshore and Domestic
4. How did you learn about the Offshore Voluntary Disclosure Program?
5. Identify the Source of Funds
U.S. Wages
U.S. Business Income
Gift/Inheritance
Foreign Wages
Foreign Business Income
Illegal Source
Other
a. Explanation
6. Has anyone, including a foreign government or a foreign financial institution, advised you that your offshore account records, which
are the subject of this voluntary disclosure, were susceptible to being turned over to the U.S. Government pursuant to an official
request?
Taxpayer
Yes
No
Spouse
Yes
No
a. If “Yes,” did you or anyone on your behalf submit documents in opposition?
Taxpayer
Yes
No
Spouse
Yes
No
14457
Catalog Number 61637F
Form
(Rev. 11-2017)
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