Form It Ta - Identity Theft Affidavit - Ohio Department Of Taxation
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IT TA
Rev. 12/14
Tax Technical/ID Theft Research
P.O. Box 182847
Columbus, OH 43218-2847
Phone: (800) 282-1780
eFax: (206) 202-5703
E-mail: OhioIDTheft@tax.state.oh.us
Identity Theft Affi davit
Full legal name
First name
M.I.
Last name
Address
City
State
ZIP
Social Security number
(only the last four digits are required)
Daytime phone
(enter only numbers, no dashes or parentheses)
E-mail address
You are required to attach a photocopy of your current driver’s license or state issued identifi cation card.
What tax year(s) are you claiming your identity was stolen?
Were you an Ohio resident during the year your identity was stolen? Yes
No
Were you required to fi le an Ohio individual income tax return? Yes
No
How did you learn of the identity theft?
Have you contacted the Internal Revenue Service (IRS)? Yes
No
If Yes, and you have completed the IRS Form 14039 (Identity Theft Affi davit), please attach a copy.
Have you fi led a police report with your local police department? Yes
No
If Yes, please attach a copy of the police report. If no, it is recommended that you fi le a police report and provide us a copy of the report.
Do you have any knowledge of the individual(s) using your Social Security number? Yes
No
If yes, please provide any information you have (i.e. name, address, phone number, etc.)
Were you incarcerated during the tax year in question? If so, you will need to provide documentation showing your admission and release
dates. Yes
No
Failure to provide all the required documents in this affi davit may delay the resolution and/or render your claim unsubstantiated.
Your signature must be notarized
I declare under the penalty of perjury that the information contained in this affi davit is true and correct to the best of my knowledge.
Signature
Date signed
Subscribed and sworn to me this
day of
, 20
Signature of notary
*If you are fi ling a paper income tax return, please mail this document to the appropriate address on the return.
If you are submitting only this notarized affi davit, please mail to the address on this form.*
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