Information Collection

Form 14039 - Identity Theft Affidavit

IC 188032 under ICR 200907-1545-012 · OMB 1545-2139.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1545-2139 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form 14039 Identity Theft Affidavit Form 14039 - Identity Theft Affidavit	Form and Instruction
Form 14039 Identity Theft Affidavit 2009 Form.pdf	Form and Instruction

IC Title:

Form 14039 - Identity Theft Affidavit

Agency IC Tracking Number:

db-2139-012

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Form 14039				Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Taxation Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	80,000	80,000
Annual IC Time Burden (Hours)	20,000	20,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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