Identity Theft Affidavit

Forms and Documents

Document Name	Status
Form 14039 Form 14039-SP - Declaración Jurada sobre el Robo de Identidad Form and Instruction	Modified
Form Form 14039 Form 14039 - Identity Theft Affidavit Form and Instruction	Modified
Supporting Statement for Form 14039.pdf Supporting Statement A	2012-09-26
OMB EXPIRATION DATE.doc Supplementary Document	2009-07-14

IC Document Collections

IC ID	Document Title	Status
188502	Form 14039-SP - Declaración Jurada sobre el Robo de Identidad Form and Instruction	Modified
188032	Form 14039 - Identity Theft Affidavit Form and Instruction	Modified

ICR Details

OMB Control No: 1545-2139	ICR Reference No: 201209-1545-016
Status: Historical Active	Previous ICR Reference No: 200907-1545-012
Agency/Subagency: TREAS/IRS	Agency Tracking No: ah-2139-012
Title: Identity Theft Affidavit
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/01/2012
	Date Received in OIRA: 09/28/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2015	36 Months From Approved	10/31/2012
Responses	100,000	0	100,000
Time Burden (Hours)	25,000	0	25,000
Cost Burden (Dollars)	0	0	0

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Abstract: 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.

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Authorizing Statute(s): US Code: 26 USC 6001 Name of Law: Notice or regulations requiring records, statements, and special returns
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 43662	07/25/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 59706	09/28/2012
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Form 14039 - Identity Theft Affidavit	Form 14039	Identity Theft Affidavit
Form 14039-SP - Declaración Jurada sobre el Robo de Identidad	14039	Declaraci?n Jurada sobre el Robo de Identidad

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ICR Summary of Burden

	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

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $8,500

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 09/28/2012

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