Form 211 - Irs Fraud Report Form
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1How Do You Report Tax Fraud to DRS?
New Tip
To assist the Department of Revenue Services with this fraud referral, please
Additional Information
complete the following information related to the person/business you are reporting.
1. Taxpayer name
2. Business name
a. Street address
a. Street address
b. City/State/ZIP
b. City/State/ZIP
c. Social Security Number (SSN)
c. CT Tax Registration Number
d. Occupation
d. Employer Identification Number
e.
e. Date of Birth
Principal Business Activity
3. Tax Type Involved (Check all that apply)
Sales & Use
Withholding
Income Tax
Alcoholic Beverage
Corporation or Business Entity
Gift
Real Estate Conveyance
Individual Use
Cigarette / Tobacco Products
Motor Fuels
Admissions & Dues
Other
4. Alleged Violation of Tax Law (check all that apply)
Failure to withhold/collect tax
False exemption
Unsubstantiated income
Smuggling
Failure to remit tax
False deductions
False / Altered Documents
Unlicensed business
Failure to file return(s)
Unreported sales
Cash wages off the books
Earned Income Tax Credit
Unregistered
Unreported purchases
Misclassified workers
Other
5. Unreported Income and Tax Years (Fill in tax years and dollar amount(s), if known e.g., TY2005 $10,000)
TY
$
| TY
$
| TY
$
| TY
$
| TY
$
| TY
$
a. Comments (Briefly describe the facts of the alleged violation – who/what/where/when/how.)
b. Are books/records available?
Yes
No
c. Do you consider the taxpayer dangerous?
Yes
No
d. Banks, financial institutions used by the taxpayer (list below)
Name
Name
Address
Address
City/State/ZIP
City/State/ZIP
e. Describe how you learned and/or obtained the information in this referral.
6. Contact information (Optional): Conn. Gen. Stat. §12-15(a) prohibits the disclosure of tax returns or tax return information. Due
to the tax return information contained in this referral DRS employees are prohibited to discuss its status or final result.
Your Name
Address
Telephone Number
City/State/ZIP
E-mail address
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Parent category: Financial