Information Collection

Form 14039 - Identity Theft Affidavit

IC 188032 under ICR 201810-1545-004 · OMB 1545-2139.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1545-2139 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form 14039 Form 14039 - Identity Theft Affidavit	Form and Instruction
Form 14039 Identity Theft Affidavit Form 14039 (Apr 2017 Rev).pdf	Form and Instruction
Form 14039 (SP) Declaracion Jurada sobre el Robo de Identidad Form 14039 (SP)(Apr 2017 Rev).pdf	Form and Instruction
FORM_14039-Burden-2018 2PG.pdf 2018 burden 14039	IC Document

IC Title:

Form 14039 - Identity Theft Affidavit

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Form 14039	Identity Theft Affidavit	Form 14039 (Apr 2017 Rev).pdf		Yes	No	Fillable Printable
Form and Instruction	Form 14039 (SP)	Declaracion Jurada sobre el Robo de Identidad	Form 14039 (SP)(Apr 2017 Rev).pdf		Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Taxation Management

Privacy Act System of Records

Title: Treas/IRS 24.030 CADE Individual Master File (IMF)

FR Citation: 80 FR 54064

Number of Respondents: 382,433

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	382,433	0	302,433	80,000
Annual IC Time Burden (Hours)	508,636	6,200	482,436	20,000
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
2018 burden 14039	FORM_14039-Burden-2018 2PG.pdf	02/06/2019

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.