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

Form 14039

Rev. February 2014

Section E - Representative Information (Required only if completing this form on someone else's behalf)

lf you are completing this form on behalf of another person, you must complete this section and attach clear and legible photocopies

of the documentation indicated.

Check only ONE of the following four boxes next to the reason why you are submitting this form

Tne taxpayer is deceased and I am the surviving spouse. (No aftachments are required)

|.- The taxpayer is deceased and I am the court-appointed or certified personal representative.

Attach a copy of the court certificate showing your appointment.

The taxpayer is deceased and a court-appointed or certified personal representative has not been appointed.

nttacn a copy of the death certificate or the formal notification from the appropriate government office informing the next of kin

of the decedent's death. Indicate your relationship to the decedent:

The taxpayer is unable to complete this form and I have been appointed conseryator or have Power of Attorney (POA) authorization.

nttacn a copy of the documentation showing your appointment as conservator or your POA authorization

lf you are the POA and have been issued a CAF number by the lRS, enter it here

OMB Number

1545-2139

Department of the Treasury - Internal Revenue Service

ldentity Theft Affidavit

Representative's name

Current mailing address

Section F - Penalty Of Perjury Statement and Signature (Required for all filers)

Under penalty of perjury, I declare that,to the best of my knowledge and belief, the information entered on this form

correct,

e , a n d m a d e i n

faith.

Signature of taxpayer or representative of taxpayer

Date signed

lnstructions for Submitting this Form

Submit this form and clear and legible copies of required documentation using ONE of the following submission options.

AND faxing this form WILL result in a processing delay

By Mail

By FAX

lf you checked Box 1 in Section A and are unable to file your return

electronically because the primary and/or secondary SSN was

misused, attach this form and documentation to your paper return and

submit to the IRS location where you normally file. lf you have already

filed your paper return, submit this form and documentation to the IRS

location where you normally file. Refer to the "Where Do You File" section

of your return instructions or visit lRS.gov and input the search term

"Where to File".

lf you checked Box 1 in Section A and are submitting this form in

response to a notice or letter received from the lRS, return this form

and documentation with a copy of the notice or letter to the address

contained in the notice or letter.

lf you checked Box 2 in Section A (you do not currently have a tax-

related issue), mail this form and documentation to:

lnternal Revenue Service

PO Box 9039

Andover MA 01810-0939

lf you checked Box 1 in Section A and are submitting this form in

response to a notice or letter received from the IRS that shows a

reply FAX number, FAX this completed form and documentation with a

copy of the notice or letter to that number. Include a cover sheet marked

"Confidential." lf no FAX number is shown, follow the mailinq instructions

on the notice or letter.

lf you checked Box 2 in Section A (you do not currently have a tax-

refated issue), FAX this form and documentation to: (855) 807-5720.

NOTE: The IRS does nol initiate contact with taxpayers by email, fax, or

any social media tools to request personal or financial information. Report

unsolicited email claiming to be from the IRS and bogus IRS websites to

phishing@irs.gov.

NOTE: For more information about questionable communications

purportedly from the lRS, visit lRS.gov and input the search term "Fake

IRS Communications".

Other helpful identity theft information may be found on wwr,v.irs.gov/uac/ldentity-Protection.

Additionally, locations and hours of operation for Taxpayer

Assistance Centers can be found at gov (search "Local Contacts").

Note: The Federal Trade Commission (FTC) is the central federal government agency responsible for identity theft awareness. The IRS does not share

taxpayer information with the FTC. Refer to the FTC's website at for additional information, protection strategies, and resourccs.

Privacy Act and Paperwork Reduction Notice

Our legal authority to request the information is 26 U.S.C 600'1.

r e q u i r e d i n f o r m a t i o n , i t m a y b e d i f i c u | t f o r | R S t o d e t e r m i n e y o u r c o r r e c t t a X l i a b i l i t y | f y o u i n t e n t i o n a | l y p r o V i d e

requrred by section 61 03

vahd OMB Control Number.

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

Department of the Treasury - Internal Revenue Service

Ldentity Theft Victim'S Complaint And Affidavit Page 8

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