Form 211 - Application For Award For Original Information

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OMB Number 1545-0409
Department of the Treasury - Internal Revenue Service
Date Claim received
Application for Award for
(March 2014)
Claim number (completed by IRS)
Original Information
1. Name of taxpayer (include aliases) and any related taxpayers who committed the violation
2. Last 4 digits of Taxpayer Identification
Number(s) (e.g., SSN, ITIN, or EIN)
3. Taxpayer's address, including ZIP code
4. Taxpayer's date of birth or approximate age
5. Name and title and contact information of IRS employee to whom violation was first reported, if known
6. Date violation reported (in number 5), if applicable
7. Did you submit this information to other Federal or State Agencies
8. If yes in number 7, list the Agency Name and date submitted
9. Is this
New submission or
Supplemental submission
If a supplemental submission, list previously assigned claim number(s)
10. Alleged Violation of Tax Law (check all that apply)
Income Tax
Employment Tax
Estate & Gift Tax
Tax Exempt Bonds
Employee Plans
Governmental Entities
Exempt Organizations
Other (identify)
11. Describe the Alleged Violation. State all pertinent facts to the alleged violation. (Attach a detailed explanation and include all supporting information
in your possession and describe the availability and location of any additional supporting information not in your possession.) Explain why you
believe the act described constitutes a violation of the tax laws
12. Describe how you learned about and/or obtained the information that supports this claim. (Attach sheet if needed)
13. What date did you acquire this information
14. What is your relationship (current and former) to the alleged noncompliant taxpayer(s)? Check all that apply. (Attach sheet if needed)
Current Employee
Former Employee
Relative/Family Member
Other (describe)
15. Do you still maintain a relationship with the taxpayer
16. If yes to number 15, describe your relationship with the taxpayer
17. Are you involved with any governmental or legal proceeding involving the taxpayer
18. If yes to number 17, Explain in detail. (Attach sheet if needed)
19. Describe the amount of tax owed by the taxpayer(s). Provide a summary of the information you have that supports your claim as to the amount owed
(i.e. books, ledgers, records, receipts, tax returns, etc). (Attach sheet if needed)
20. Fill in Tax Year (TY) and Dollar Amount ($), if known
21. Name of individual claimant
22. Claimant's date of birth (MMDDYYYY)
23. Last 4 digits of Claimant's SSN or ITIN
24. Address of claimant, including ZIP code
25. Telephone number (including area code)
26. Email address
27. Declaration under Penalty of Perjury I declare that I have examined this application, all accompanying statement and supporting documentation, and,
to the best of my knowledge and belief, they are true, correct, and complete
Signature of Claimant
Catalog Number 16571S
(Rev. 3-2014)


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