Fillable Form R-2000 - Louisiana Identity Theft Affidavit printable pdf download

Form R-2000 - Louisiana Identity Theft Affidavit

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R-2000 (7/12)

Louisiana Identity Theft Affidavit

Louisiana Department of Revenue

Criminal Investigations Division

P.O. Box 2389

Baton Rouge, LA 70821-2389

Email: fraud.mailbox@la.gov

PLEASE PRINT OR TYPE

Please check on of the following boxes:

 I am a victim of identity theft and I believe this incident is affecting my tax records (Provide a short explanation of the tax impact)

 I am a victim of identity theft and believe I may be at risk for future impact to my tax account

 I am a potential victim of identity theft and believe I may be at risk for future impact to my tax account. (You should 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 and/or date the incident occurred

Last tax return filed (year) (Enter NRF if not required to file)

(if applicable or known)

Taxpayer’s last name

First name

Middle Initial

Provide the last 4 digits of your Social Security Number

(SSN) or your complete Individual Taxpayer Identification

Number (ITIN)

Taxpayer’s 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

Telephone number

 Home

 Work

 Cell

Best time(s) to call

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, com-

plete, and made in good faith.

(Signature of taxpayer)

(Date signed mm/dd/yyyy)

Please submit this completed form and a photocopy of at least one of the following documents to verify your identity.

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

 a) Passport

 c) Social Security Card

 b) Driver’s license

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

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

Please submit the photocopies required above with this form to the address listed at the top of the form.