Louisiana Identity Theft Affidavit
Louisiana Department of Revenue
Criminal Investigations Division
P.O. Box 2389
Baton Rouge, LA 70821-2389
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
Provide the last 4 digits of your Social Security Number
(SSN) or your complete Individual Taxpayer Identification
Taxpayer’s current mailing address
Address on last tax return filed (Check here if you are not required to file a tax return)
Best time(s) to call
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)
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.