Identity Theft Affidavit

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Emergency Request memo.doc	Justification for No Material/Nonsubstantive Change	Uploaded 2009-02-11	Repair queued
Supporting Statement for Form 14039.pdf	Supporting Statement A	Uploaded 2009-02-11	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
188032	Form 14039 - Identity Theft Affidavit	Instruction	New

ICR Details

OMB Control No: 1545-2139	ICR Reference No: 200902-1545-007
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: TREAS/IRS	Agency Tracking No: Response requested by 2/19/09
Title: Identity Theft Affidavit
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 02/19/2009
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/23/2009
	Date Received in OIRA: 02/18/2009
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2009	6 Months From Approved
Responses	100,000	0	0
Time Burden (Hours)	25,000	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The primary purpose of the form is to provide a method of reporting identity theft issues to the IRS so that the IRS may document situations where individuals are or may be victims of identity theft. Additional purposes include the use in the determination of proper tax liability and to relieve taxpayer burden. The information may be disclosed only as provided by 26 U.S.C 6103.

Emergency Justfication: We have developed Form 14039 - Identity Theft Affidavit as a vehicle for taxpayers to identify themselves to us as victims or potential victims of identity theft. We are requesting that OMB expedite the approval process for Form 14039 for the following reasons: See attached memorandum.

---

Authorizing Statute(s): US Code: 26 USC 6001 Name of Law: Notice or regulations requiring records, statements, and special returns
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Form 14039 - Identity Theft Affidavit

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	100,000	0	0	100,000	0	0
Annual Time Burden (Hours)	25,000	0	0	25,000	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Form 14039 is critical to prevent the disruption of the collection of information. This form has been developed to replace our use of the Federal Trade Commission’s Affidavit of Identity Theft (hereafter “FTC Affidavit”) as that form has proved confusing and burdensome for our customers. The burden increase is based on the estimated number of responses.

---

Annual Cost to Federal Government: $8,500

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 02/18/2009

---