Form 14039 - Identity Theft Affidavit

Form 14039 (Rev. XX-200X)

Identity Theft Affidavit Department of the Treasury – Internal Revenue Service

OMB No. 1545-XXXX

Please 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 any questionable activity.

Please check one:

 I am a victim of identity theft and I believe this incident is impacting my tax records.

 I am (circle one): (a victim) (a potential victim) of identity theft and believe I may be at risk for future impact to my tax account.

(You should circle “potential victim” if you have not experienced identity theft but are at risk due to a lost/stolen purse or wallet, questionable credit card or credit report activity, etc.)

Full Name (print last, first, middle)	Last 4 digits of Social Security Number (SSN)or your Individual Tax Identification Number (ITIN)
Current Mailing Address	Address on last tax return filed OR  I am not required to file a tax return
Tax year(s) impacted (if applicable or known)	Last tax return filed (year): ____________ (Enter NRF if not required to file)
Telephone number: ( ) ________________ Best time(s) to call:	Primary Language:  English  Spanish  Other _____________

Please submit this form and a photocopy of at least one of the following documents to verify your identity:

1. Passport c) Social Security Card

2. Driver’s license d) Other valid U.S. Federal or State government issued identification**

Under penalty of perjury, I declare that, to the best of my knowledge and belief, the information in this form is true, correct, complete, and made in good faith.

Signature: ____________________________ Date: (mm/dd/yyyy) _______________

Please submit the photocopies required above with this form using one of the following options:
BY MAIL:	BY FAX:
If you received a notice from the IRS, return this form with a copy of the notice to the address contained in the notice. If you have not received a notice and are self-reporting as an actual or potential victim of identity theft, please mail this form to: Internal Revenue Service PO Box 9039 Andover, MA 01810-0939 USA	If you received a notice in the mail from the IRS and a fax number is shown, fax this form with a copy of the notice to that number. Please include a cover sheet marked “Confidential.” If no fax number is shown, please follow the mailing instructions. NOTE: The IRS does not initiate contact with taxpayers by e-mail or fax. If you have not received a notice and are self-reporting as an actual or potential victim of identity theft, fax this form to: (978) 247-9965 NOTE: (This is not a toll-free number. Your telephone company or a third party service provider, if applicable, may charge to send faxes.)

For Privacy Act and Paperwork Reduction Act Notice, see page 2.

** Please do not submit photocopies of federally issued identification where proscribed by 18 U.S.C. 701 (e.g., official badges designating federal employment).

Other helpful IRS identity theft information may be found at http://www.irs.gov (click on “Individuals,” then click on “Identity Theft and Your Tax Records”). Additionally, information on your local IRS Taxpayer Assistance Center, including location and hours of operation, can be found at http://www.irs.gov/localcontacts/index.html.

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. Please refer to the FTC’s website at http://www.ftc.gov (keyword “identity theft”) for additional information, protection strategies, and resources.

Privacy Act and Paperwork Reduction Act Notice

Our legal authority to request the information is 26 USC 6001.

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.

Providing the information on this form is voluntary. However, if you do not provide the information it may be more difficult to assist you in resolving your identity theft issue. If you are a potential victim of identity theft and do not provide the required substantiation information, we may not be able to place a marker on your account to assist with future protection. If you are a victim of identity theft and do not provide the required information, it may be difficult for IRS to determine your correct tax liability. If you intentionally provide false information, you may be subject to criminal penalties.

You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by section 6103.

Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have comments concerning the accuracy of these time estimates or suggestions for making this form simpler, we would be happy to hear from you. You can write to the Internal Revenue Service, Tax Products Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW, IR-6526, Washington, DC 20224.

Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be subject to a penalty for failure to comply with, a collection of information subject to the requirements of the Paperwork Reduction Act, unless that collection of information displays a currently valid OMB Control Number.

Do not send this form to this address. Instead, see the form for filing instructions.

Catalog Number 54525A Form 14039 (Rev. XX-200X)