Form -- Offshore Voluntary Disclosures Letter

Form

Department of the Treasury–Internal Revenue Service

14457

(January 2013)

Offshore Voluntary Disclosure Letter

If taxpayer has domestic issues only, please have them apply for a traditional voluntary
disclosure.

OMB Number
1545-XXXX

Submit Form 14457 to: Internal Revenue Service
Voluntary Disclosure Coordinator
1-D04-100
2970 Market Street
Philadelphia, PA 19104
To assist in a timely determination of acceptance into the Voluntary Disclosure Program (for Voluntary Disclosures involving offshore
accounts), the Taxpayer must address all of the following items.
1a. Taxpayer Name

1b. Taxpayer Identification Number

1c. Taxpayer Date of Birth

1d. Taxpayer Address
1e. Passport Number

1f. Country

1g. Current Occupation

2a. Taxpayer Representative

2b. Phone Number

2c. Address of Taxpayer Representative
3. Type of Voluntary Disclosure

Offshore Only
4. Source of the Funds (If additional space is needed, attach a statement)

Offshore and Domestic

5. Have any of the offshore accounts you are disclosing been identified by the IRS as ineligible for this
program?

Yes

No

6. Has anyone, including a foreign government or a foreign financial institution, advised you that your
offshore account records, which are the subject of this voluntary disclosure, were susceptible to being
turned over to the U.S. Government pursuant to an official request?

Yes

No

a. If “Yes,” did you or anyone on your behalf submit documents in opposition?

Yes

No

b. If “Yes,” were copies of those documents provided to the Attorney General of the United States as
required by 18 USC §3506?

Yes

No

7. Are you or any related entities currently under audit or criminal investigation by the Internal Revenue
Service or any other law enforcement authority?

Yes

No

a. Has the IRS notified you that it intends to commence an examination or investigation?

Yes

No

b. Are you under criminal investigation by any law enforcement authority?
c. If “Yes,” please explain.

Yes

No

Yes

No

8. Do you believe that the IRS has obtained information concerning your tax liability?
If “Yes,” please specify.

Catalog Number 61637F

www.irs.gov

Form 14457 (1-2013)

Form

Department of the Treasury–Internal Revenue Service

14457

(January 2013)

Offshore Voluntary Disclosure Letter

If taxpayer has domestic issues only, please have them apply for a traditional voluntary
disclosure.

OMB Number
1545-XXXX

9. Please check the box to estimate the annual range of the highest aggregate value of your offshore accounts.
Tax Year
Tax Year
Tax Year
Tax Year
Tax Year
Tax Year
Tax Year
Highest Aggregate
Account/Asset Value

Tax Year

$0 to $100,000
$100,000 to $1,000,000
$1,000,000 to $2,500,000
$2,500,000 to $10,000,000
$10,000,000 to $100,000,000
Greater than $100,000,000
10. Please check the box to estimate the range of potential total unreported income from the offshore account(s) during each disclosure
period.
Tax Year
Tax Year
Tax Year
Tax Year
Tax Year
Tax Year
Tax Year
Tax Year
Estimated Total
Unreported Income
$0 to $100,000
$100,000 to $1,000,000
$1,000,000 to $2,500,000
$2,500,000 to $10,000,000
$10,000,000 to $100,000,000
Greater than $100,000,000
For each foreign financial account of which you have control or are a beneficial owner, complete the attached Form 14454, Attachment
to Offshore Voluntary Disclosures. Please ensure all pages of the attachment include your name, the last four digits of your taxpayer
identification number, the name of the foreign financial institution, and the account number for which you are responding.
To be included with all Forms 14457:
By signing this document, I certify that I am willing to continue to cooperate with the Internal Revenue Service, including in assessing
my income tax liabilities and making good faith arrangements to pay all taxes, interest, and penalties associated with this voluntary
disclosure.
Under penalties of perjury, I declare that I have examined this document, all attachments, and accompanying statements, and to the
best of my knowledge and belief, they are true, correct, and complete.
Signature of Taxpayer

Print Name

Date

Signature of Taxpayer's Spouse

Print Name

Date

IRS reserves the right to make further contacts with the taxpayer to clarify his/her submission.

Privacy Act and Paperwork Reduction Act Notice
We ask for the information on this foreign account or asset statement to carry out the Internal Revenue laws of the United States. Our authority to ask for information is
sections 6001, 6109, 7801, 7803 and the regulations thereunder. This information will be used to determine and collect the correct amount of tax under the terms of the
offshore voluntary disclosure program. You are not required to apply for participation in the offshore voluntary disclosure program. If you choose to apply, however, you are
required to provide all the information requested on the foreign account or asset statement.
You are not required to provide the information requested on a document that is subject to the Paperwork Reduction Act unless the document displays a valid OMB control
number. Books or records relating to a document or its instructions must be retained as long as their contents may become material in the administration of any Internal
Revenue law. Generally, tax returns and return information are confidential, as required by section 6103. Section 6103, however, allows or requires the Internal Revenue
Service to disclose or give this information to others as described in the Internal Revenue Code. For example, we may disclose this information to the Department of Justice to
enforce the tax laws, both civil and criminal, and to cities, states, the District of Columbia, and U.S. commonwealths or possessions to carry out their tax laws. We may also
disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and
intelligence agencies to combat terrorism. Failure to provide this information may delay or prevent processing your application. Providing false information may subject you to
penalties.
The time needed to complete and submit the foreign account or asset statement will vary depending on individual circumstances. The estimated average time is: 2 hour.
If you have comments concerning the accuracy of this time estimate or suggestions for making the foreign account or asset statement simpler, we would be happy to hear
from you. Comments should be sent to the Internal Revenue Service, Attn: IRS Reports Clearance Officer, SE:W:CAR:MP:T:T:SP, Washington, DC 20224.

Catalog Number 61637F

www.irs.gov

Form 14457 (1-2013)