EFTA01222615.pdf

Department of the Treasury - Internal Revenue Service Form 14039 OMB Number (April 2017) Identity Theft Affidavit 1545-2139 Complete this form if you need the IRS to mark an account to identify questionable activity. Section A - Check the following boxes in this section that apply to the specific situation you are reporting (Required for au filers) ❑ 1. I am submitting this Form 14039 for myself ❑ 2. This Form 14039 is submitted in response to a 'Notice' or 'Letter' received from the IRS • Please provide 'Notice' or 'Letter' number(s) on the line to the right • Please check box 1 in Section Et 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' • Please complete Section E on reverse side of this form. Caution: If filing this on behalf of your 'dependent child or dependent relative'. filing this form will protect his or her tax account but it will not prevent the victim in Section C below from being claimed as a dependent by another person. ❑ 4. I am submitting this Form 14039 on behalf of another person (other than my dependent child or dependent relative) • Please complete Section E on reverse side of this form. Section B — Reason For Filing This Form (Required) Check only ONE of the following boxes that apply to the person listed in Section C below. ❑ 1. Someone used my information to file taxes ❑ 2. I don't know if someone used my information to file taxes, but I'm a victim of identity theft Please provide an explanation of the identity theft issue. how you became aware of it and provide relevant dates. If needed. please 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 Taxpayer Identification Number initial (Please provide 9.cfigit Social Security Number) Current mailing address (apartment or suite number and street. or P.O. Box) If deceased, please provide last known address Current city State ZIP code Tax Year(s) you experienced identity theft (If not known. enter 'Unknown' in one box below) What is the last year you filed a return Address used on last filed tax return (If different than 'Current) Names used on last filed tax return (If different than 'Current) City (on last tax return filed) State ZIP code Telephone number with area code (Optional) 11deceased. please indicate 'Deceased' Best time(s) to call Home telephone number Cell phone number Language in which you would like to be contacted ❑ English ❑ Spanish Section D — 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 his form. Catalog Number 52525A WWWirSpOv Form 14039 (Rev. 4-2017) EFTA01222615  Page 2 Section E — Representative, Conservator, Parent or Guardian Information (Requiredit 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. O 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 El ParenVLegal Guardian E Other lj 4. The taxpayer is unable to complete this form and I am the appointed conservator or have Power of Attorney/Declaration of Representative authorization per IRS Form 2848 • Attach a copy of documentation showing your appointment as conservator or POA authorization. • If you have an IRS issued Centralized Authorization File (CAF) number, enter the nine-digit number: O 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. • Indicate your relationship to person: El ParenVLegal Guardian O Fiduciary Relationship per IRS Form 56 O Power of Attorney O Other Representative's name Last name I First name I 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: • Choose one method of submitting this form either by Mail or by FAX, not both. • Please provide clear and readable photocopies of any additional information you may choose to provide. • Note that 'tax returns' may not be submitted to either the mailing address or FAX number. Submitting by Mail Submitting by FAX • If you checked Box 1 in Section B in response to a notice or • If you checked Box 1 in Section B of Form 14039 and are letter received from the IRS. return this form and if possible, a submitting this form in response to a notice or letter received copy of the notice or letter to the address contained in the from the IRS. If it provides a FAX number, you should send notice or letter. there. • If you checked Box 1 in Section B of Form 14039, are unable If no FAX number is shown on the notice or letter, please follow to file your tax return electronically because the primary and/ the mailing instructions on the notice or letter. or secondary SSN was misused, attach this Form 14039 to the • Include a cover sheet marked 'Confidential'. back of your paper tax return and submit to the IRS location where you normally file your tax return. • If you checked Box 2 in Section B of Form 14039 (no current tax-related issue), FAX this form toll-free to: • If you've already filed your paper return, please submit this Form 14039 to the IRS location where you normally file. Refer to 855-807-5720 the 'Where Do You File' section of your return instructions or visit IRS.gov and input the search term 'Where to File'. • If you checked Box 2 in Section B of Form 14039 (no current tax-related issue). mail this form to: Department of the Treasury Internal Revenue Service Fresno, CA 93888-0025 Privacy Act and Paperwork Reduction Notice QS algal atelionly to toquosi iho intonnatan is 26 U.S.C. 6001. Rio pnmary paoso Cl Inc lo/ms to 00'00 a monad al cononno slaron non ltaJoa ID Ma IRS so 'hal The RS may decurnorn SikabOnS NeCf0 Ind/AS/SS area may to mains olldenity well addbonal ponCoes indode tause mine delermirobon 01pope' la k a- cl to reline la/Payer bonlan. Tie in/dna/on maybe eisRecd Crlyms worded by 26 U SC. 6103. PronIng the recnneon on INS turn t noluniary. 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If" °O, " og " t",00" , "" ihnI":1"9 Inonnni el the ton. no Ammo is naLned I, Manna 0a nor stag an/ parson be ' ,knell, a perully ler bate lo conm4 min acolecoon of nlornabon st.tioci to Ito roqutemora al Ire Ploorennk Roaslon Ap unto:.:'t coloosa of nrorrnalandscroys a ortrool/i valid OMB Conn/ futtor. Catalog Number 52525A www.irs.gov Form 14039 (Rev. 4-2017) EFTA01222616