Form 211 - Application For Award For Original Information
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2OMB No. 1545-0409
Department of the Treasury - Internal Revenue Service
Form 211
Date Claim Received:
Application for Award for
(Rev. December 2007)
Original Information
Claim No. (completed by IRS)
2. Claimant's Date of Birth
3. Claimant's SSN or ITIN
1. Name of individual claimant
Month
Day
Year
5. Spouse's Date of Birth
6. Spouse's SSN or ITIN
4. Name of spouse
(if applicable)
Month
Day
Year
7. Address of claimant, including zip code, and telephone number
8. Name & Title of IRS employee to whom violation was reported
9. Date violation reported:
10. Name of taxpayer (include aliases) and any related taxpayers who committed the violation:
11. Taxpayer Identification Number(s) (e.g.,
SSN, ITIN, or EIN):
12. Taxpayer's address, including zip code:
13. Taxpayer's date of birth or approximate
age:
14. State the facts pertinent to the alleged violation. (Attach a detailed explanation and all supporting information in your possession
and describe the availability and location of any additional supporting information not in your possession.) Explain why you believe the
act described constitutes a violation of the tax laws.
15. Describe how you learned about and/or obtained the information that supports this claim and describe your present or former
relationship to the alleged noncompliant taxpayer(s). (Attach sheet if needed.)
16. Describe the amount owed by the taxpayer(s). Please provide a summary of the information you have that supports your claim as
to the amount owed. (Attach sheet if needed.)
Declaration under Penalty of Perjury
I declare under penalty of perjury that I have examined this application, my accompanying statement, and supporting documentation
and aver that such application is true, correct, and complete, to the best of my knowledge.
18. Date
17. Signature of Claimant
MAIL THE COMPLETED FORM TO THE ADDRESS SHOWN ON THE BACK
211
Form
(Rev. 12-2007)
Catalog Number 16571S
publish.no.irs.gov
Department of the Treasury-Internal Revenue Service
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