Form Ftb 3552 Pc C1 - Identity Theft Affidavit - State Of California Identity Theft Team
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1
2STATE OF CALIFORNIA
IDENTITY THEFT TEAM MS A462
FRANCHISE TAX BOARD
PO BOX 2952
SACRAMENTO CA 95812-2952
Identity Theft Affidavit
Complete and submit this form if you are an actual or potential victim of identity theft and would like the Franchise Tax
Board (FTB) to update your account status to identify questionable activity.
Check one of the following boxes:
I am a victim of identity theft, and I believe this incident is affecting my tax account. Provide a short explanation of
the tax impact:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
I am a victim of identity theft, and I believe I may be at risk for future impact to my tax account.
I am a potential victim of identity theft, and I believe I may be at risk for future impact to my tax account. (Check
“potential victim” if you have not experienced identity theft but are at risk due to a lost/stolen purse or wallet,
questionable credit card or credit report activity, etc.)
Tax Year(s) Impacted
Date the Incident Occurred
Last Tax Return Filed (Year) (Enter NRF if Not Required to File.):
(if applicable or known):
(if applicable or known):
Last Name:
First Name:
Middle Initial:
Provide the last 4 digits of your Social Security Number or your
complete Individual Taxpayer Identification Number:
Current Mailing Address:
City:
State:
ZIP Code:
Address on Last Tax Return Filed (Check Here If You Are Not Required to File a Tax Return.):
City:
State:
ZIP Code:
Best Time (s) to Call:
Telephone Number:
Home
Work
Cell
Primary Language:
English
Spanish
Other
Specify:
Under penalty of perjury, I declare that, to the best of my knowledge and belief, the information entered in
this form is true, correct, complete, and made in good faith. I hereby agree and consent that the facsimile/fax
signature of this affidavit shall be considered as valid as the original.
___________________________________________________________
________________________________
Taxpayer Signature
Date Signed (mm/dd/yyyy)
Submit this completed form and a copy of at least one of the following documents to verify your identity.
(Check the box next to the document you are submitting.)
a) Passport
b) Driver license or Department of Motor Vehicles identification card
If available, include a copy of:
c) Social security card
d) Police report
e) Internal Revenue Service letter of determination
Submit the copies required above with this form using one of the options described on PAGE 2 of this form.
PAGE 1
FTB 3552 PC C1 (NEW 06-2012)
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