Form 14039 - Identity Theft Affidavit

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Department of the Treasury - Internal Revenue Service
OMB Number
Form 14039
Identity Theft Affidavit
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
The last 4 digits of the taxpayer’s SSN or the taxpayer’s
complete Individual Taxpayer Identification Number (ITIN)
Taxpayer's current mailing address (apt., suite no. and street, or P.O. Box)
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)
ZIP code
Section C – Telephone Contact Information (Required for all filers)
Telephone number (include area code)
Best time(s) to call
I prefer to be contacted in (select the appropriate language)
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:
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).
Department of the Treasury - Internal Revenue Service
(Rev. 12-2012) Catalog Number 52525A


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