Fillable Form 14039 - Identity Theft Affidavit printable pdf download

Department of the Treasury - Internal Revenue Service

OMB Number

Form 14039

Identity Theft Affidavit

1545-1648

Rev. December 2012

Complete and submit this form if you are an actual or potential victim of identity theft and would like the IRS to mark your account to

identify any questionable activity.

Check only one of the following two boxes if they apply to your specific situation. (Optional for all filers)

I am submitting this form in response to a mailed notice or letter from the IRS.

I am completing this form on behalf of another person, such as a deceased spouse or other deceased relative. You

should provide information for the actual or potential victim in Sections A, B, & D.

Note to all filers: Failure to provide required information on BOTH sides of this form AND clear and legible documentation

will delay processing.

Section A – Reason For Filing This Form (Required for all filers)

Check only ONE of the following two boxes. You MUST provide the requested description or explanation in the lined area below.

I am a victim of identity theft AND it is affecting my

I have experienced an event involving my personal information

federal tax records.

that may at some future time affect my federal tax records.

You should check this box if, for example, your attempt

You should check this box if you are the victim of non-federal

to file electronically was rejected because someone had

tax related identity theft, such as the misuse of your personal

already filed using your Social Security Number (SSN)

identity information to obtain credit. You should also check this

or Individual Taxpayer Identification Number (ITIN), or if

box if no identity theft violation has occurred, but you have

you received a notice or correspondence from the IRS

experienced an event that could result in identity theft, such as

indicating someone was otherwise using your number.

a lost/stolen purse or wallet, home robbery, etc.

Provide a short explanation of the problem and how

Briefly describe the identity theft violation(s) and/or the

you were made aware of it.

event(s) of concern. Include the date(s) of the incident(s).

Section B – Taxpayer Information (Required for all filers)

Taxpayer's last name

First name

Middle

The last 4 digits of the taxpayer’s SSN or the taxpayer’s

complete Individual Taxpayer Identification Number (ITIN)

initial

Taxpayer's current mailing address (apt., suite no. and street, or P.O. Box)

City

State

ZIP code

Tax year(s) affected

Last tax return filed (year) (If you are not required to file a return,

(Required if you checked box 1 in Section A above)

enter NRF and do not answer the next two questions)

Address on last tax return filed (If same as current address, write “same as above”)

City (on last tax return filed)

State

ZIP code

Section C – Telephone Contact Information (Required for all filers)

Telephone number (include area code)

Best time(s) to call

Home

Work

Cell

I prefer to be contacted in (select the appropriate language)

English

Spanish

Other

Section D – Required Documentation (Required for all filers)

Submit this completed form and a clear and legible photocopy of at least one of the following documents to verify your identity. If you

are submitting this form on behalf of another person, the documentation should be for that person. If necessary, enlarge the

photocopies so all information and pictures are clearly visible.

Check the box next to the document(s) you are submitting:

Passport

Driver's license

Social Security Card

Other valid U.S. Federal or State government issued identification**

** Do not submit photocopies of federally issued identification where prohibited by 18 U.S.C. 701 (e.g., official badges designating federal employment).

14039

Department of the Treasury - Internal Revenue Service

Form

(Rev. 12-2012) Catalog Number 52525A

Form 14039 - Identity Theft Affidavit

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