Form 14039 (Rev. 12-2011)
Department of the Treasury — Internal Revenue ServiceCatalog Number 52525A
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.
Privacy Act and Paperwork Reduction Act Notice
Other helpful identity theft information may be found on www.irs.gov (keyword "identity theft"). Additionally, locations and hours of
operation for Taxpayer Assistance Centers can be found at http://www.irs.gov/localcontacts/index.html.
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. Please refer to the FTC's website at http://www.ftc.gov (keyword "identity theft")
for additional information, protection strategies, and resources.
www.irs.gov
If you received a notice from the IRS, return this form with a
copy of the notice to the address contained in the notice. If you
are unable to file your return electronically because the primary
and/or secondary SSN was misused, submit this form with your
paper return to the IRS location for your state. If you have already
filed your return, submit the form with a letter of explanation to the
IRS location for your state. Refer to the "Where Do You File"
section of your return instructions.
If you have not received an IRS notice and are self-reporting as
being at risk for future impact to
your tax account, please mail this form to:
Internal Revenue Service
P.O. Box 9039
Andover, MA 01810-0939
USA
If you received a notice in the mail from the IRS and a fax
number is shown, fax this completed form with a copy of the
notice to that number. Please include a cover sheet marked
"Confidential." If no fax number is shown, please follow the
mailing instructions.
NOTE: The IRS does not initiate contact with taxpayers by
e-mail or fax.
If you have not received an IRS notice and are self-reporting as
being at risk for future impact to your tax account, fax this form
to: (978) 684-4542.
NOTE: This is not a toll-free number. Your telephone company
or a third party service provider, if applicable, may charge to
send faxes.
Please submit the photocopies required above with this form using one of the following options
BY MAIL BY FAX
