14693 Application for Reduced Rate of Withholding on Whistlebl

Form

14693

(February 2017)

Department of the Treasury - Internal Revenue Service

OMB Number
1545-2273

Application for Reduced Rate of Withholding
on Whistleblower Award Payment

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

1. Claimant
a. Name of individual claimant
Last

First

MI

c. Name of spouse (if applicable)
Last

First

MI

b. Claimant TIN (Social Security Number or Individual Taxpayer ID
Number (last four digits only))

d. Spouse's TIN (Social Security Number or Individual Taxpayer ID

e. Address (street, city, provence/state, postal/ZIP code, country (if not USA))

Number (last four digits only))

f. Claim number(s)
g. Telephone number

2. Name of Attorney Whose Fees Will be Deducted (if applicable)
a. Name of Attorney
Last

First

MI

b. Address (street, city, provence/state, postal/ZIP code, country (if not USA))

c. Telephone number

3. Attorney Fees and Court Costs
a. 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 $
b. Are any amounts of the attorney fees paid on a contingency basis (check one)

Yes

No

4. Attachments to Substantiate Fees and Costs
a. Copy of contingency fee agreement or other fee agreement between the claimant and the claimant's attorney.
b. Copies of bills to substantiate the amount of attorney fees incurred in connection with award under section 7623(b).
c. Copies of bills to substantiate the amount of court costs incurred in connection with award under section 7623(b).
d. 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
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.

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
Catalog Number 67566P

www.irs.gov

Form 14693 (2-2017)

Page 2

Instructions for Application for Reduced Rate of Withholding on Whistleblower Award
Payment, Form 14693
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.
Please read the instructions before completing the form.
Claimant
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
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

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

Attach Documents to Substantiate Attorney Fees and Court Costs
4a. Agreement between claimant and attorney
4b. Bills of attorney fees
4c. Bills of court costs
4d. Other documents to support attorney fees and court costs

Declaration Section
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.

Catalog Number 67566P

www.irs.gov

Form 14693 (2-2017)