Form 13997 Validating Your TIN and Reasonable Cause

Department of the Treasury — Internal Revenue Service

Form

13997

Validating Your TIN and Reasonable Cause

(October 2009)

OMB No. 1545-2144

1. If you have a TIN, please provide your correct SSN and/or TIN and a written statement of reasonable cause in the
respective spaces provided below:
Your Social Security Number (SSN)

Your Taxpayer Identification Number (TIN)
b.

a.

c. Written Statement of Reasonable Cause (attach separate page(s) if necessary).

2. If you do not have a TIN, please provide us a statement explaining why you do not have a TIN or SSN (attach
separate page(s) if necessary).

Under penalties of perjury, I declare that the facts presented in this form and as set out in the
accompanying statement of facts, schedules, and other statements are, to the best of my
knowledge and belief, true, correct, and complete.
Taxpayer
Attestation

Print your name

Your Signature

Date (mmddyyyy)

Privacy Act Statement
The information solicited on a passport application is requested pursuant to provisions of Titles 8, 18, and 22 of the United States Code, including 22 U.S.C. 211a, 212, 213,
and regulations issued pursuant to Executive Order 11295 (August 5, 1966), including part 51, Title 22, Code of Federal Regulations (CFR). Failure to provide certain
information requested on a passport application may subject you to a $500 penalty under Internal Revenue Code section 6039E. The Internal Revenue Service's legal right to
ask for this information is section 6039E.
We ask for this information to carry out the Internal Revenue laws of the United States. The primary purpose for soliciting the information is to establish whether you are liable
for a penalty under Internal Revenue Code section 6039E. Your response is mandatory. Failure to provide the information requested on this form, or providing false or
fraudulent information, may subject you to further penalties. In particular, false statements made knowingly and willfully in passport applications or in affidavits or other
supporting documents submitted therewith are punishable by fine and/or imprisonment under the provisions of 18 U.S.C. §§ 1001 and/or 1542.
We may disclose this information to the Department of Justice for civil or criminal litigation, and to other federal agencies as provided by law. We may also give it to cities,
states, the District of Columbia, and U.S. commonwealths or possessions to carry out their laws. We may give it to foreign governments pursuant to treaties with the United
States. We may disclose this information to federal and state agencies to enforce federal non-tax laws, or federal law enforcement and intelligence agencies to combat
terrorism.

Catalog Number 51669T

www.irs.gov

Form 13997 (10-2009)