Form 3949-A Information Referral

Form 3949
(2-2007)

Department of the Treasury – Internal Revenue Service

A

Information Referral

OMB # 1545-1960

(See instructions on reverse)

1. Taxpayer Name

2. Business Name

a. Street Address

a. Street Address

b. City/State/ZIP

b. City/State/ZIP

c. Social Security Number (SSN)

c. Employer Identification Number

d. Occupation

d. Principal Bus Activity

e. Date of Birth
3. Marital Status
Married
Divorced

3a. Name of Spouse
Head of Household

Single
Separated

4. Alleged Violation of Income Tax Law (Check all that apply).
False Exemption

Unsubstantiated Income

Unreported Income

Failure to Withhold Tax

False Deductions

Kickback

Narcotics Income

Wagering/Gambling

Multiple Filing

False/Altered Documents

Public/Political Corruption

Earned Income Credit

Organized Crime

Failure to Pay Tax

Failure to File Return

Other (Describe below)

5. Unreported Income and Tax Years (Fill in Tax Years and dollar amount(s), if known, e.g., TY2005 $10,000)
TY

$

TY

$

TY

$

TY

$

TY

$

TY

$

a. Comments (Briefly describe the facts of the alleged violation - Who/What/Where/When/How. Attach another sheet, if needed).

b. Are books/records available?
Yes
No
d. Banks, Financial Institutions used by the taxpayer:
Name:
Address:
City/State/ZIP:

c. Do you consider the taxpayer dangerous?
Yes
No
Name:
Address:
City/State/ZIP:

e. Please describe how you learned and/or obtained the information in this report (Attach another sheet, if needed):

6. Your Name:
a. Address:
b. City/State/ZIP:
c. Telephone Number (Please include the Area Code):
For Mailing Address, see Instructions
For Paperwork Reduction Act, see Instructions

Catalog Number 47872E

Form 3949 A (Rev. 2-2007)

Instructions
Provide the following information for the Person/Business You Are Reporting if Known:
1. Name
a. Street Address of Residence
b. City, State, and Zip Code
c. Social Security Number
d. Date of the Person’s Birth

2. Business Name
a. Street Address of Business
b. City/State/Zip Code
c. Enter Employer Identification Number
d. Describe the Primary Business Activity

3. Indicate Martial Status
M - Married S - Single HH - Head of Household Div - Divorced Sep - Separated
3a. Enter name of spouse, if applicable.
4. Check all Tax Violations That Apply to Your Report or Describe in Comments If Not Listed.
5. If your report involves unreported income, indicate the year(s) and the dollar amount(s)
5a. Briefly describe the facts of the alleged violation(s) as you know them. Please attach another sheet, if you need
more room.
5b. Indicate (Yes or No) if books and/or records are available that substantiate your report.
5c. Indicate (Yes or No) if you consider the person to be violent or dangerous and provide an explanation in the
comments section of this form.
5d. List name and address of bank(s) and/or financial institution(s) used by the taxpayer if known.
5e. Briefly explain how you learned of or obtained the information contained in your report. Please attach another
sheet, if you need more room.
6. Enter your name, street address, city, state, zip code and a telephone number where you can be contacted. Indicate
time of day you may be contacted if appropriate. This Information is not Required to Process Your Report.
Please print and send your completed form to the Internal Revenue Service at:
Internal Revenue Service
Fresno, CA 93888

PAPERWORK REDUCTION NOTICE: We ask for the information on this form to carry out the Internal Revenue laws
of the United States. This report is voluntary and the information requested helps us determine if there has been a
violation of Income Tax Law. We need it to insure that taxpayers are complying with these laws and to allow us to
figure and collect the right amount of tax.
You are not required to provide the information 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 administrations of any Internal Revenue laws. Generally, tax returns
and tax return information are confidential, as required by Code section 6103.
The time required to complete this form will vary depending on individual circumstances. The estimated average time
is 15 minutes.
Privacy Act Notice
We are requesting this information under authority of 26 U.S.C. 7801.
The primary purpose of this form is to report potential violations of the Internal Revenue laws.
The information may be disclosed to the Department of Justice to enforce the tax laws.
Providing the information is voluntary. Not providing all or part of the information will not affect you.

Catalog Number 47872E

Form 3949 A (Rev. 2-2007)