Fillable Form 14039 - Identity Theft Affidavit (Page 2 of 2) in pdf

Department of the Treasury - Internal Revenue Service

OMB Number

Form 14039

Identity Theft Affidavit

1545-2139

Rev. February 2014

Section E – Representative Information (Required only if completing this form on someone else’s behalf)

If you are completing this form on behalf of another person, you must complete this section and attach clear and legible photocopies

of the documentation indicated.

Check only ONE of the following four boxes next to the reason why you are submitting this form

The taxpayer is deceased and I am the surviving spouse. (No attachments are required)

The taxpayer is deceased and I am the court-appointed or certified personal representative.

Attach a copy of the court certificate showing your appointment.

The taxpayer is deceased and a court-appointed or certified personal representative has not been appointed.

Attach a copy of the death certificate or the formal notification from the appropriate government office informing the next of kin

of the decedent’s death. Indicate your relationship to the decedent:

The taxpayer is unable to complete this form and I have been appointed conservator or have Power of Attorney (POA) authorization.

Attach a copy of the documentation showing your appointment as conservator or your POA authorization.

If you are the POA and have been issued a CAF number by the IRS, enter it here:

Representative's name

Current mailing address

City

State

ZIP code

Section F – Penalty Of Perjury Statement and Signature (Required for all filers)

Under penalty of perjury, I declare that, to the best of my knowledge and belief, the information entered on this form is true, correct,

complete, and made in good faith.

Signature of taxpayer or representative of taxpayer

Date signed

Instructions for Submitting this Form

Submit this form and clear and legible copies of required documentation using ONE of the following submission options.

Mailing AND faxing this form WILL result in a processing delay.

By Mail

By FAX

If you checked Box 1 in Section A and are unable to file your return

If you checked Box 1 in Section A and are submitting this form in

electronically because the primary and/or secondary SSN was

response to a notice or letter received from the IRS that shows a

misused, attach this form and documentation to your paper return and

reply FAX number, FAX this completed form and documentation with a

submit to the IRS location where you normally file. If you have already

copy of the notice or letter to that number. Include a cover sheet marked

filed your paper return, submit this form and documentation to the IRS

"Confidential." If no FAX number is shown, follow the mailing instructions

location where you normally file. Refer to the "Where Do You File" section

on the notice or letter.

of your return instructions or visit IRS.gov and input the search term

"Where to File".

If you checked Box 2 in Section A (you do not currently have a tax-

related issue), FAX this form and documentation to: (855) 807-5720.

If you checked Box 1 in Section A and are submitting this form in

response to a notice or letter received from the IRS, return this form

and documentation with a copy of the notice or letter to the address

NOTE: The IRS does not initiate contact with taxpayers by email, fax, or

contained in the notice or letter.

any social media tools to request personal or financial information. Report

unsolicited email claiming to be from the IRS and bogus IRS websites to

If you checked Box 2 in Section A (you do not currently have a tax-

phishing@irs.gov.

related issue), mail this form and documentation to:

NOTE: For more information about questionable communications

Internal Revenue Service

purportedly from the IRS, visit IRS.gov and input the search term "Fake

PO Box 9039

IRS Communications".

Andover MA 01810-0939

Other helpful identity theft information may be found on Additionally, locations and hours of operation for Taxpayer

Assistance Centers can be found at

(search “Local Contacts").

Note: The Federal Trade Commission (FTC) is the central federal government agency responsible for identity theft awareness. The IRS does not share

taxpayer information with the FTC. Refer to the FTC's website at

for additional information, protection strategies, and resources.

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.

14039

Department of the Treasury - Internal Revenue Service

Form

(Rev. 2-2014) Catalog Number 52525A