Fillable Application for Reduced Rate of Withholding on Whistleblower Award Payment Feb-2017 Form-14693

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Application for Reduced Rate of Withholding on Whistleblower Award Payment Feb-2017 Form-14693

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The Application for Reduced Rate of Withholding on Whistleblower Award Payment Feb-2017 Form-14693 form is 1 page long and contains:

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  • 2 check-boxes
  • 19 other fields

Country of origin: US
File type: PDF

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The Internal Revenue Service (IRS) is a government agency responsible for collecting taxes and administering the federal statutory tax laws of the United States. The IRS provide tax assistance to taxpayers and pursue and resolve fraudulent tax filings.

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Catalog Number 67566P www.irs.gov
Form
14693 (2-2017)
Form 14693
(February 2017)
Department of the Treasury - Internal Revenue Service
Application for Reduced Rate of Withholding
on Whistleblower Award Payment
OMB Number
1545-2273
Date Form 14693 was sent to claimant (IRS use only)
1. Claimant
a. Name of individual claimant
Last First MI
b. Claimant TIN (Social Security Number or Individual Taxpayer ID
Number (last four digits only))
c. Name of spouse (if applicable)
Last First MI
d. Spouse's TIN (Social Security Number or Individual Taxpayer ID
Number (last four digits only))
e. Address (street, city, provence/state, postal/ZIP code, country (if not USA)) f. Claim number(s)
g. Telephone number
2. Name of Attorney Whose Fees Will be Deducted (if applicable)
a. Name of Attorney
Last First MI
b. Address
(street, city, provence/state, postal/ZIP code, country (if not USA))
c. Telephone number
3. Attorney Fees and Court Costs
a. Amount of deduction for attorney fees and court costs paid or to be paid in connection with an award under section 7623(b), that
claimant intends to claim on a federal income tax return
$
b. Are any amounts of the attorney fees paid on a contingency basis (check one) Yes No
4. Attachments to Substantiate Fees and Costs
a. Copy of contingency fee agreement or other fee agreement between the claimant and the claimant's attorney.
b. Copies of bills to substantiate the amount of attorney fees incurred in connection with award under section 7623(b).
c. Copies of bills to substantiate the amount of court costs incurred in connection with award under section 7623(b).
d. Any other information to substantiate a deduction for attorney fees and court costs incurred in connection with an award under
section 7623(b).
Declaration Under Penalty of Perjury
Under penalties of perjury, I declare that I have examined the application, including any accompanying documents, schedules, exhibits,
affidavits, and statements and to the best of my knowledge and belief it is true, correct and complete.
Signature of Claimant or Authorized Representative Date
Send completed form, along with supporting attachments to:
Internal Revenue Service
Whistleblower Office
1111 Constitution Ave., NW
Washington, DC 20224
Note: If an Authorized Representative signs this form, provide a valid Form 2848, Power of Attorney and Declaration of Representative,
with original signatures.
click to sign
signature
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dd mmm yyyy
Page 2
Catalog Number 67566P www.irs.gov
Form
14693 (2-2017)
Instructions for Application for Reduced Rate of Withholding on Whistleblower Award
Payment, Form 14693
Use this form ONLY if you have been notified that you are due to receive a whistleblower award under Section 7623(b)
and you want to reduce the rate of withholding on the award. To be considered for a reduced withholding rate, the
application (Form14693) must be received by the Whistleblower Office within 30 days from the date printed on the form.
Please read the instructions before completing the form.
Claimant
1a.
Enter the last name, first name, and middle initial of the claimant
1b.
Enter the last, first and middle initial of the claimant’s spouse, if applicable
1c.
Enter address information
1d.
Enter the last four digits of the Claimant’s Identification Number (SSN, ITIN, etc)
1e.
Enter the claim numbers
1f.
Enter the phone number
Attorney
2a.
Enter the last name, first name, and middle initial of the attorney whose fees will be deducted
2b.
Enter address information
2c.
Enter the phone number
Attorney Fees and Court Costs
3.
Enter the dollar amount you intend to deduct on your tax return for (a) Attorney Fees and (b) Court Costs
Attach Documents to Substantiate Attorney Fees and Court Costs
4a.
Agreement between claimant and attorney
4b.
Bills of attorney fees
4c.
Bills of court costs
4d.
Other documents to support attorney fees and court costs
Declaration Section
The claimant or his or her authorized representative may sign the declaration statement. This request will not be
considered complete or valid if the declaration statement is not signed with an original signature and date. If signed by an
authorized representative, provide a valid Form 2848, Power of Attorney and Declaration of Representative, with original
signatures and date.
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Application for Reduced Rate of Withholding on Whistleblower Award Payment Feb-2017 Form-14693

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Completed 18 May 2019

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