Form 8821-A IRS Disclosure Authorization for Victims of Identity The

Version A, Cycle 1
OMB No. 1545-1165

Form

For IRS Use Only

8821-A

IRS Disclosure Authorization
for Victims of Identity Theft

March 2012
Department of the Treasury
Internal Revenue Service

Received by:
Name
Telephone
Function
Date

Taxpayer name

Taxpayer identification number

Daytime telephone number

Spouse's name (if applicable)

Taxpayer identification number

Daytime telephone number

Taxpayer mailing address

City

State

ZIP code

Year or period requested
Enter the ending date of the year or period, using the
mm/dd/yyyy format. If you are requesting more than
six years or periods, you must attach another Form 8821-A.
I/We,

, consent for the Internal Revenue Service
(Name(s) of taxpayer)

to disclose to

, of
(Name and Title of recipient official)

(Name/Address/Phone number of State/Local law enforcement agency)

any return information, as defined by 26 U.S.C. § 6103(b)(2), related to the processing of a purported “return” that may have been filed
by a third party using my name and/or social security number without my knowledge or consent for the tax year(s) listed above. Such
return information includes the purported return itself, communications between myself and IRS personnel and any other information
gathered or generated by the IRS in the processing of the purported return, including the IRS's determination that such return was not a
valid return. Such return information would not include the identity of, or any investigatory information regarding, the person(s) who may
have filed the purported return.

DRAFT AS OF
March 27, 2012

I understand that the state or local law enforcement agency designated above may use this information to investigate and/or prosecute
any persons who may have been involved in the filing of the purported return or other crimes related to the use of my identifying
information. I further understand that the state or local law enforcement agency designated above may share this information with other
law enforcement agencies directly involved in this or other related investigations and/or prosecutions of crimes related to the use of my
identifying information by these persons.
Signature of taxpayer(s). If a tax matter applies to a joint return, either husband or wife must sign.
Note: Do not sign this form if it is blank or incomplete.
Signature

Signature

Print name

Date signed

Print name

Date signed

IRS regulations require that this disclosure authorization be received by the IRS within 120 days of the date that it is signed by the
taxpayer.

Privacy Act Notice
We ask for the information on this form to carry out the Internal Revenue laws of the United States. This form authorizes the IRS to disclose your
confidential tax information to the person/agency you appoint. This form is provided for your convenience and its use is voluntary. The information is
used by the IRS to determine what confidential tax information your appointee can inspect and/or receive. Section 6103(c) and its regulations require
you to provide this information if you want to appoint a designee to inspect and/or receive your confidential tax information. Under section 6109, you
must disclose your social security or other taxpayer identification number. If you do not provide all the information requested on the form, we may not be
able to honor the authorization. Providing false or fraudulent information may subject you to penalties. We may disclose this information to the
Department of Justice for civil or criminal litigation, and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in
administering their tax laws. We may also disclose this information to other countries under a tax treaty, to Federal and state agencies to enforce
Federal non-tax criminal laws, or to Federal law enforcement and intelligence agencies to combat terrorism.
www.irs.gov/form8821

Catalog Number 59482M

Form

8821-A (3-2012)