Form 3949-A - Information Referral
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1
2
3Department of the Treasury - Internal Revenue Service
3949-A
Form
OMB Number
Information Referral
1545-1960
(April 2016)
(See instructions on reverse)
Use this form to report suspected tax law violations by a person or a business.
CAUTION: READ THE INSTRUCTIONS BEFORE COMPLETING THIS FORM. There may be other more appropriate forms specific to your complaint.
(For example, if you suspect your identity was stolen, use
Form
14039.)
Section A – Information About the Person or Business You Are Reporting
Complete 1, if you are reporting an Individual. Complete 2, if you are reporting a business only. Complete 1 and 2 if you are reporting a business and its owner.
(Leave blank any lines you do not know.)
1a. Name of individual
b. Social Security Number/TIN
c. Date of birth
d. Street address
e. City
f. State
g. ZIP code
h. Occupation
i. Email address
j. Marital status (check one, if known)
k. Name of spouse
Married
Single
Head of Household
Divorced
Separated
2a. Name of business
b. Employer Tax ID number (EIN)
c. Telephone number
d. Street address
e. City
f. State
g. ZIP code
h. Email address
i. Website
Section B – Describe the Alleged Violation of Income Tax Law
3. Alleged violation of income tax law. (Check all that apply.)
False Exemption
Unsubstantiated Income
Unreported Income
Failure to Withhold Tax
False Deductions
Earned Income Credit
Narcotics Income
Failure to File Return
Multiple Filings
Public/Political Corruption
Kickback
Failure to Pay Tax
Organized Crime
False/Altered Documents
Wagering/Gambling
Other (describe in 5)
4. Unreported income and tax years
Fill in Tax Years and dollar amounts, if known (e.g., TY 2010- $10,000)
TY
$
TY
$
TY
$
TY
$
TY
$
TY
$
5. Comments (Briefly describe the facts of the alleged violation-Who/What/Where/When/How you learned about and obtained the information in this report. Attach
another sheet, if needed.)
6. Additional information. Answer these questions, if possible. Otherwise, leave blank.
a. Are book/records available? (If available, do not send now. We will contact you, if they are needed for an investigation.)
Yes
No
b. Do you consider the taxpayer dangerous?
Yes
No
c. Banks, Financial Institutions used by the taxpayer
Name
Name
Street address
Street address
City
State
ZIP code
City
State
ZIP code
Section C – Information About Yourself
(We never share this information with the person or business you are reporting.)
This information is not required to process your report, but would be helpful if we need to contact you for any additional information.
7a. Your name
b. Telephone number
c. Best time to call
d. Street address
e. City
f. State
g. ZIP code
Please print and send your completed form to: Internal Revenue Service
Stop 31313
Fresno, CA 93888
3949-A
Catalog Number 47872E
Form
(Rev. 4-2016)
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