Form 14693 Application for Reduced Rate of Withholding on Whistlebl

Form 14693 (February 2015)

Department of the Treasury - Internal Revenue Service Application for Reduced Rate of Withholding on Whistleblower Award Payment

OMB Number 1545-xxxx

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_R Date Form 14693 was sent to claimant (IRS use only) _O

1. Claimant

a. Name of individual claimant			b. Claimant TIN (Social Security Number or Individual Taxpayer ID Number (last four digits only))
Last	First	MI
c. Name of spouse (if applicable)			d. Spouse's TIN (Social Security Number or Individual Taxpayer ID Number (last four digits only))
Last	First	MI
e. Address (street, city, provence/state, postal/ZIP code, country (if not USA))			f. Claim number(s)
			g. Telephone number

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F

^T F

2. a. Name of Attorney
   Last	First	MI
   b. Address (street, city, provence/state, postal/ZIP code, country (if not USA))
   			c. Telephone number

   
   

   Name of Attorney Whose Fees Will be Deducted (if applicable) _O ^C R

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3. Y

   E

   Attorney Fees and Court Costs

1. Amount of deduction for attorney fees and court costs paid or to be paid in connection with an award under section 7623(b), that claimant intends to claim on a federal income tax return _$

2. L

   Are any amounts of the attorney fees paid on a contingency basis (check one) Yes No

4. Attachments to Substantiate Fees and Costs

   1. Copy of contingency fee agreement or other fee agreement between the claimant and the claimant's attorney.

   2. E

      Copies of bills to substantiate the amount of attorney fees incurred in connection with award under section 7623(b).

   3. Copies of bills to substantiate the amount of court costs incurred in connection with award under section 7623(b).

   4. A

      Any other information to substantiate a deduction for attorney fees and court costs incurred in connection with an award under section 7623(b).

Declaration Under Penalty of Perjury

S

Under penalties of perjury, I declare that I have examined the application, including any accompanying documents, schedules, exhibits, affidavits, and statements and to the best of my knowledge and belief it is true, correct and complete.

E

Signature of Claimant or Authorized Representative Date

Note: If an Authorized Representative signs this form, provide a valid Form 2848, Power of Attorney and Declaration of Representative, with original signatures.

Send completed form, along with supporting attachments to:

Internal Revenue Service Whistleblower Office

1111 Constitution Ave., NW Washington, DC 20224

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Page 2

Instructions for Application for Reduced Rate of Withholding on Whistleblower Award

Payment, Form 14693

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Use this form ONLY if you have been notified that you are due to receive a whistleblower award under Section 7623(b) and you want to reduce the rate of withholding on the award. To be considered for a reduced withholding rate, the application (Form14693) must be received by the Whistleblower Office within 30 days from the date printed on the form.

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Please read the instructions before completing the form.

Claimant

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^1a. Enter the last name, first name, and middle initial of the claimant

^1b. Enter the last, first and middle initial of the claimant’s spouse, if applicable

^1c. Enter address information

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F

^1d. Enter the last four digits of the Claimant’s Identification Number (SSN, ITIN, etc)

^1e. Enter the claim numbers

^1f. Enter the phone number

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Attorney

^2a. Enter the last name, first name, and middle initial of the attorney whose fees will be deducted

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^2b. Enter address information

^2c. Enter the phone number

Attorney Fees and Court Costs

^3. Enter the dollar amount you intend to deduct on your tax return for (a) Attorney Fees and (b) Court Costs

_O Attach Documents to Substantiate Attorney Fees and Court Costs

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^4a. Agreement between claimant and attorney

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^4b. Bills of attorney fees

^4c. Bills of court costs

Other documents to support attorney fees and court costs

Y

E

4d.

Declaration Section

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The claimant or his or her authorized representative may sign the declaration statement. This request will not be considered complete or valid if the declaration statement is not signed with an original signature and date. If signed by an authorized representative, provide a valid Form 2848, Power of Attorney and Declaration of Representative, with original signatures and date.

Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Section 6109 requires that you provide your identifying number on what you file. This is so we know who you are, and can process your form.

Generally, tax returns and return information are confidential, as required by section 6103. However, we may give the information to the Department of Justice and to other federal agencies, as provided by law. 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.

You are not required to provide the Information requested 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 administration of any Internal Revenue law.

The estimated time needed to prepare and file this form is 45 minutes.

Form 14693 (2-2015)

Catalog Number 67566P

www.irs.gov