Identity Theft Affidavit

ICR 201209-1545-016

OMB: 1545-2139

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Form and Instruction
Modified
Supporting Statement A
2012-09-26
Supplementary Document
2009-07-14
ICR Details
1545-2139 201209-1545-016
Historical Active 200907-1545-012
TREAS/IRS ah-2139-012
Identity Theft Affidavit
Extension without change of a currently approved collection   No
Regular
Approved without change 11/01/2012
Retrieve Notice of Action (NOA) 09/28/2012
  Inventory as of this Action Requested Previously Approved
11/30/2015 36 Months From Approved 10/31/2012
100,000 0 100,000
25,000 0 25,000
0 0 0

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.

US Code: 26 USC 6001 Name of Law: Notice or regulations requiring records, statements, and special returns
  
None

Not associated with rulemaking

  77 FR 43662 07/25/2012
77 FR 59706 09/28/2012
No

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 100,000 100,000 0 0 0 0
Annual Time Burden (Hours) 25,000 25,000 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$8,500
No
No
No
No
No
Uncollected
Jerry Olivarez 9723081729

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
09/28/2012


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