Ldentity Theft Victim'S Complaint And Affidavit (Page 7 of 8) in pdf

Form 14039

Rev. February 2014

Complete and submit this form if you are an actual or potential victim of identity theft and would like the IRS to mark your account to

identify questionable activity.

Check only one of the following two boxes if they apply to your specific situation. (Optional for all filers)

| am submitting this form in response to a mailed notice or letter from the lRS.

| am completing this form on behalf of another person, such as a deceased spouse or other deceased relative. You

should provide information for the actual or potential victim in Sections A, B, & D.

Note to all filers: Failure to provide required information on BOTH sides of this form AND clear and legible documentation

will delay processing.

THIS FORM MUST BE SIGNED ON THE REVERSE SIDE (SECTION F).

OMB Number

1545-2139

Department ofthe Treasury - Internal Revenue Service

ldentity Theft Affidavit

Section A - Reason For Filing This Form (Required for all filers)

Check only ONE of the following two boxes. You MUST provide the requested description or explanation in the lined area below.

1 !

| am a victim of identity theft AND it is affecting my

federal tax records.

You should check this box if, for example, your attempt

to file electronically was rejected because someone had

already filed using your Social Secuity Number (SSN)

or Individual Taxpayer ldentification Number (lTlN), or if

you received a notice or correspondence from fhe /RS

indicating someone was otherwise using your number-

Provide a short explanation of the problem and how

you were made aware of it.

2 E

I have experienced an event involving my personal information

that may at some future time affect my federal tax records.

You should check this box if you are the victim of non-federal

tax related identity theft, such as fhe mlsuse of your personal

identity information to obtain credit. You should also check this

box if no identity theft violation has occuned, but you have

experienced an event that could result in identity theft, such as

a losUstolen purse orwallet, home robbery, etc.

Briefly describe the identity theft violation(s) and/or the

event(s) of concern. lnclude the date(s) of the incident(s).

Section B - Taxpayer Information (Required for all filers)

Taxpayer's current mailing address (apt., suite no. and street, or P.O. Box)

Taxpayer's last name

City

Tax year(s) affected (Required if you checked box 1 in Section A above)

The last 4 digits of the taxpayer's SSN or the taxpayer's

complete Individual Taxpayer ldentification Number (lTlN)

ZIP code

Last tax return filed (year) (lf you are not required to file a return, enter

NRF and do not complete the next two lines)

Address on last tax return fted (lf same as cunent address, wite "same as above")

City (on last tax return flled)

Section C - Telephone Contact lnformation (Required for all filers)

Telephone number (include area code) !

Home

Work

Ceil

Best time(s) to call

I prefer to be contacted in (se/ecf the appropiate language)

English

Spanish

Other

Section D - Required Documentation (Required for all filers)

Submit this completed form and a clear and legible photocopy of at least one of the following documents to verify your identity. lf you

are submitting this form on behalf of another person, the documentation should be for that person. lf necessary, enlarge the

photocopies so all information and pictures are clearlv visible.

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

Passport !

Driver's license !

Sociat Security Card I

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

"* Do not submit photocopies of federally issued identification

where prohibited by 18 U.S.C. 701 (e.9., official badges designating federal employment).

rorm 14039 (Rev.2-2014) Catalog Number 52525A

Department of the Treasury - lnternal Revenue Service

Ldentity Theft Victim'S Complaint And Affidavit Page 7

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