Form 14039 Form 14039 Identity Theft Affidavit

Form

14039

Department of the Treasury - Internal Revenue Service

OMB Number
1545-2139

Identity Theft Affidavit

(March 2022)

This affidavit is for victims of identity theft. To avoid delays do not use this form if you have already filed a Form 14039 for this incident.
The IRS process for assisting victims selecting Section B, Box 1 below is explained at irs.gov/victimassistance.
Get an IP PIN: We encourage everyone to opt-in to the Identity Protection Personal Identification Number (IP PIN) program. If you don’t
have an IP PIN, you can get one by going to irs.gov/ippin. If unable to do so online, you may schedule an appointment at your closest
Taxpayer Assistance Center by calling (844-545-5640). Or, if eligible, you may use IRS Form 15227 to apply for an IP PIN by mail or FAX,
also available by going to irs.gov/ippin.
Section A - Check the following boxes in this section that apply to the specific situation you are reporting (required for all filers)
1. I am submitting this Form 14039 for myself
2. I am submitting this Form 14039 in response to an IRS Notice or Letter received
• Provide ‘Notice’ or ‘Letter’ number(s) on the line to the right
• Check box 1 in Section B and see special mailing and faxing instructions on reverse side of this form.
3. I am submitting this Form 14039 on behalf of my dependent child or dependent relative
• Complete Sections A-F of this form. Do not use this form If dependent’s identity was misused by a parent or guardian in filing
taxes, this is not identity theft.
4. I am submitting this Form 14039 on behalf of another person living or deceased (other than my dependent child or dependent relative)
• Complete Sections A- F of this form.
Section B – How I Am Impacted (required when reporting misuse of Social Security Number (SSN) or Individual Taxpayer Identification Number (ITIN))
Check all boxes that apply to the person listed in Section C below. If the person in Section C has previously submitted a Form 14039 for
the same incident, there’s no need to submit another Form 14039.
1. I know that someone used my information to fraudulently file a tax return
I/My dependent was fraudulently/incorrectly claimed as a dependent
My SSN or ITIN was fraudulently used for employment purposes
2. I don’t know if someone used my information to fraudulently file taxes, but I’m a victim of identity theft
Provide an explanation of the identity theft issue, how it impacts your tax account, when you became aware of it and provide relevant
dates. If needed, attach additional information and/or pages to this form

Section C – Name and Contact Information of Identity Theft Victim (required)
Victim’s last name

First name

Middle
initial

Current mailing address (apartment or suite number and street, or P.O.
Box) If deceased, provide last known address

Taxpayer Identification Number
(provide 9-digit SSN or ITIN)

Current city

State

ZIP code
-

Address used on last filed tax return (if different than ‘Current’)

City (on last tax return filed)

State

ZIP code
-

Telephone number with area code
Home phone number

Best time(s) to call
Cell phone number

Language in which you would like to be contacted

English

Spanish

Other

Section D – Tax Account Information: Last tax return filed (year shown on the tax return) and Returns Impacted (Do not complete
Section D if you selected Box 2 in Section B above)

I had no filing requirement or filed a non-filer return
Names used on last filed tax return

The last tax return filed (year shown on the tax return)

What Tax Year(s) you believe were impacted by tax-related identity theft (example: 2020 is input for citing the 2020 tax return though filed the
next year(s). (if not known, enter ‘Unknown’ below))

Section E – Penalty of Perjury Statement and Signature (required)
Under penalty of perjury, I declare that, to the best of my knowledge and belief, the information entered on this Form 14039 is true, correct,
complete, and made in good faith.
Signature of taxpayer, or representative, conservator, parent or guardian

Date signed

Submit this completed form to either the mailing address or the FAX number provided on the reverse side of this form.
Catalog Number 52525A

www.irs.gov

Form 14039 (Rev. 3-2022)

Section F – Representative, Conservator, Parent or Guardian Information (required if completing Form 14039 on someone else’s behalf)
Check only ONE of the following five boxes next to the reason you are submitting this form
1. The taxpayer is deceased, and I am the surviving spouse
• No attachments are required, including death certificate.
2. The taxpayer is deceased, and I am the court-appointed or certified personal representative
• Attach a copy of the court certificate showing your appointment.
3. The taxpayer is deceased, and a court-appointed or certified personal representative has not been appointed
• Attach copy of death certificate or formal notification from a government office informing next of kin of the decedent’s death.
• Indicate your relationship to decedent:
Child
Parent/Legal Guardian
Other
4. The taxpayer is unable to complete this form and I am the appointed conservator, or I have been authorized to act on
behalf of the taxpayer per Form 2848, Power of Attorney and Declaration of Representative
• Attach a copy of documentation showing your appointment as conservator or Power of Attorney authorization.
• If you have an IRS issued Centralized Authorization File (CAF) number, enter the nine-digit number:
5. The person is my dependent child or my dependent relative
By checking this box and signing below you are indicating that you are an authorized representative, as parent, guardian or legal
guardian, to file a legal document on the dependent’s behalf.
Parent/Legal Guardian
Power of Attorney
• Indicate your relationship to person
Fiduciary per IRS Form 56, Notice of Fiduciary Relationship
Other
Representative's name
Last name

First name

Middle initial

Representative’s current mailing address (city, town or post office, state, and ZIP code)
Representative’s telephone number
Instructions for Submitting this Form
Submit this completed and signed form to the IRS via Mail or FAX to specialized IRS processing areas dedicated to assist you.
In Section C of this form, be sure to include the Social Security Number in the ‘Taxpayer Identification Number’ field.
Help us avoid delays:
• Do not use this form if you have already filed a Form 14039 for this incident.
• Choose one method of submitting this form either by Mail or by FAX, not both.
• Provide clear and readable photocopies of any additional information you may choose to provide.
• Submit the original tax return to the IRS location where you normally file your tax return. Do not use the following address or fax
number to file an original tax return.
Submitting by Mail

Submitting by FAX

• If you checked Box 2 in Section A in response to a notice or
letter received from the IRS, return this form and if possible, a
copy of the notice or letter to the address contained in the
notice or letter.
• If you checked Box 1 or 2 in Section B of Form 14039 and are
unable to file your tax return electronically because the SSN/
ITIN of you, your spouse, or dependent was misused, attach
this Form 14039 to the back of your paper tax return and
submit to the IRS location where you normally file your tax return.
• All others should mail this form to:
Department of the Treasury
Internal Revenue Service
Fresno, CA 93888-0025

• Always include a cover sheet marked "Confidential”.
• If you checked Box 2 in Section A of Form 14039 and are
submitting this form in response to a notice or letter received
from the IRS. If it provides a FAX number, you should send
there.
• If no FAX number is shown on the notice or letter, follow the
mailing instructions on the notice or letter.
• For all others, FAX this form toll-free to:
855-807-5720

Privacy Act and Paperwork Reduction Notice
Our legal authority to request the information is 26 U.S.C. 6001. 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. Providing the information on this form is voluntary. However, if you do not provide the information it may be more difficult to
assist you in resolving your identity theft issue. If you are a potential victim of identity theft and do not provide the required substantiation information, we may not be able to place a marker on
your account to assist with future protection. If you are a victim of identity theft and do not provide the required information, it may be difficult for IRS to determine your correct tax liability. If you
intentionally provide false information, you may be subject to criminal penalties. 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. Generally, tax returns and return information are confidential, as required by section 6103. Public reporting burden for this collection of information is
estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. If you have comments concerning the accuracy of these time estimates or suggestions for making this form simpler, we would be happy to hear from you.
You can write to the Internal Revenue Service, Tax Products Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW, IR-6526, Washington, DC 20224. Do not send this
form to this address. Instead, see the form for filing instructions. Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be subject to a penalty
for failure to comply with, a collection of information subject to the requirements of the Paperwork Reduction Act, unless that collection of information displays a currently valid OMB Control
Number.

Catalog Number 52525A

www.irs.gov

Form 14039 (Rev. 3-2022)