Catalog Number 59482M www.irs.gov
Form
8821-A (Rev. 3-2020)
Form 8821-A
(March 2020)
Department of the Treasury - Internal Revenue Service
IRS Disclosure Authorization
for Victims of Identity Theft
OMB Number 1545-1165
For IRS Use Only
Received by:
Name
Telephone
Function
Date
Taxpayer Information
Taxpayer name Social Security Number Daytime telephone number
Taxpayer mailing address
City State ZIP code
Tax year
(enter the tax year for which your return, and any purported return, was filed. If there are additional years, you must complete and submit
another Form 8821-A for each year)
Taxpayer Consent
I,
(Name of taxpayer)
, consent for the Internal Revenue Service to disclose to
(Name and Title of recipient official)
, of
(Name of State/Local law enforcement agency) (Phone number)
,
(Street address of State/Local law enforcement agency (street, city, state, ZIP code))
,
any information related to the processing of my return, or any purported return that may have been filed by a third party using my name
and/or social security number without my knowledge or consent, for the tax year listed above. This information includes the return I
filed, any purported return filed by a third party, communications between myself and IRS personnel and any other information gathered
or generated by the IRS in the processing of my return or any purported return, including the IRS's determination that such return was
not my return. This information would not include the identity of, or any investigatory information regarding, the person(s) who may
have filed the purported return.
I understand that the state or local law enforcement agency designated above may use this information to investigate and/or prosecute
any person(s) who may have been involved in the filing of the purported return or other crimes related to the use of my identifying
information. I further understand that the state or local law enforcement agency designated above may share this information with other
law enforcement agencies directly involved in this or other investigations and/or prosecutions of crimes related to the use of my
identifying information by these persons.
Taxpayer Signature
I certify that I am the taxpayer whose name and/or social security number was used to file my return, or any purported return. If signed
by a guardian, executor, receiver, administrator, trustee or party other than the taxpayer, I certify that I have the authority to sign this
form with respect to this matter.
Note: Do not sign this form if it is blank or incomplete. The IRS will only accept forms with original signatures.
Signature Date signed
Print name Title (if applicable)
IRS regulations require that this disclosure authorization be received by the IRS within 120 days of the date that it is signed by the
taxpayer.
Taxpayer Notification
Internal Revenue Code, Section 6103(c), limits disclosure and use of return information provided pursuant to your consent and holds
the recipient subject to penalties, brought by private right of action, for any unauthorized access, other use, or redisclosure without your
express permission or request.
Designated Recipient Official Notification
Internal Revenue Code, Section 6103(c), limits disclosure and use of return information received pursuant to the taxpayer’s consent
and holds the recipient subject to penalties for any unauthorized access, other use, or redisclosure without the taxpayer’s express
permission or request.
