Catalog Number 61637F www.irs.gov
Form
14457 (Rev. 11-2017)
Form 14457
(November 2017)
Department of the Treasury–Internal Revenue Service
Offshore Voluntary Disclosure Letter
If taxpayer has domestic issues only, please have them apply for a traditional voluntary disclosure.
OMB Number
1545-2241
Submit Form 14457 to: Internal Revenue Service
Voluntary Disclosure Coordinator
1-D04-100
2970 Market Street
Philadelphia, PA 19104
To assist in a timely determination of acceptance into the Voluntary Disclosure Program (for Voluntary Disclosures involving offshore
accounts), the Taxpayer must address all of the following items. All answers and attachments must be in English.
If you filed jointly at any point during the past eight years, your spouse should also apply for the OVDP by answering the
questions below.
Date
1a. Name
Spouse
Taxpayer
1b. Taxpayer Identification Number
Spouse
Taxpayer
1c. Date of Birth
Spouse
Taxpayer
1d. Address
Spouse
Taxpayer
1e. Telephone number
Spouse
Taxpayer
For items 1f through 1k, attach additional sheets, if necessary.
1f. Passport Number(s)
Spouse
Taxpayer
1g. Country(ies)
Spouse
Taxpayer
1h. Current Occupation
Spouse
Taxpayer
1i. Bank Name(s)
Spouse
Taxpayer
1j. Name on Bank Account
Spouse
Taxpayer
1k. Bank Account Number(s)
Spouse
Taxpayer
Note: Estates must include a court document or Form 56 verifying who is authorized to sign the Form 2848.
2a. Taxpayer Representative 2b. Phone Number
2c. Address of Taxpayer Representative
2d. Email address of Taxpayer Representative
3. Type of Voluntary Disclosure
Offshore Only Offshore and Domestic
4. How did you learn about the Offshore Voluntary Disclosure Program?
5. Identify the Source of Funds
U.S. Wages U.S. Business Income Gift/Inheritance Foreign Wages
Foreign Business Income Illegal Source Other
a. Explanation
6. Has anyone, including a foreign government or a foreign financial institution, advised you that your offshore account records, which
are the subject of this voluntary disclosure, were susceptible to being turned over to the U.S. Government pursuant to an official
request?
Taxpayer
Yes No
Spouse
Yes No
a. If “Yes,” did you or anyone on your behalf submit documents in opposition?
Taxpayer
Yes No
Spouse
Yes No
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Catalog Number 61637F www.irs.gov
Form
14457 (Rev. 11-2017)
b. If “Yes,” were copies of those documents provided to the Attorney General of the United States as required by 18 USC §3506?
Taxpayer
Yes No
Spouse
Yes No
7. Disclose if you or any related entities currently under audit or criminal investigation by the Internal Revenue Service or any other law
enforcement authority?
a. Has the IRS notified you, your spouse or any related entities that it intends to commence an examination or investigation?
Taxpayer
Yes No
Spouse
Yes No
Related entities
Yes No
b. Are you, your spouse or any related entities under criminal investigation by any law enforcement authority?
Taxpayer
Yes No
Spouse
Yes No
Related entities
Yes No
c. If “Yes,” explain.
8. Do you believe that the IRS has obtained information concerning your tax liability?
Yes No
If “Yes,” specify.
a. Please list all of your accounts (attach additional sheets, if necessary)
9. During the disclosure period, have you taken a position that you were a bona fide resident of a U.S. territory
(e.g., American Samoa, the Commonwealth of the Northern Mariana Islands, Guam, Puerto Rico, or the U.S.
Virgin Islands) or did you file an income tax return with a U.S. territory?
Yes No
If “Yes,” list the territory and tax years.
10. Please check the box to estimate the annual range of the highest aggregate value of your offshore accounts.
Highest Aggregate
Account/Asset Value
$0 to $100,000
$100,000 to $1,000,000
$1,000,000 to $2,500,000
$2,500,000 to $10,000,000
$10,000,000 to $100,000,000
Greater than $100,000,000
Tax Year Tax Year Tax Year Tax Year Tax Year Tax Year Tax Year Tax Year
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Catalog Number 61637F www.irs.gov
Form
14457 (Rev. 11-2017)
For each foreign financial account of which you have control or are a beneficial owner, complete the attached Form 14454, Attachment
to Offshore Voluntary Disclosure Letter. Please ensure all pages of the attachment include your name, the last four digits of your
taxpayer identification number, the name of the foreign financial institution, and the account number for which you are responding.
To be included with all Forms 14457:
By signing this document, I certify that I am willing to continue to cooperate with the Internal Revenue Service, including in assessing
my income tax liabilities and making good faith arrangements to pay all taxes, interest, and penalties associated with this voluntary
disclosure.
Under penalties of perjury, I declare that I have examined this document, all attachments, and accompanying statements, and to the
best of my knowledge and belief, they are true, correct, and complete.
Estimated Total
Unreported Income
$0 to $100,000
$100,000 to $1,000,000
$1,000,000 to $2,500,000
$2,500,000 to $10,000,000
Greater than $10,000,000
Tax Year Tax Year Tax Year Tax Year Tax Year Tax Year Tax Year Tax Year
Signature of Taxpayer Print Name Date
Signature of Taxpayer's Spouse Print Name Date
Signature must be original (must be mailed), preferably in blue ink. Photocopied, facsimile, or electronic signatures are not
acceptable. The power of attorney may not sign the voluntary disclosure letter on behalf of the taxpayers.
IRS reserves the right to make further contacts with the taxpayer to clarify his/her submission.
Privacy Act and Paperwork Reduction Act Notice
We ask for the information on this foreign account or asset statement to carry out the Internal Revenue laws of the United States. Our authority to ask for information is
sections 6001, 6109, 7801, 7803 and the regulations thereunder. This information will be used to determine and collect the correct amount of tax under the terms of the
offshore voluntary disclosure program. You are not required to apply for participation in the offshore voluntary disclosure program. However, if you choose to apply you are
required to provide all the information requested on the offshore voluntary disclosure letter.
You are not required to provide the information requested on a document that is subject to the Paperwork Reduction Act unless the document displays a valid OMB control
number. Books or records relating to a document 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. Section 6103, however, allows or requires the Internal Revenue
Service to disclose or give this information to others as described in the Internal Revenue Code. For example, we may disclose this information to the Department of Justice to
enforce the tax laws, both civil and criminal, and to cities, states, the District of Columbia, and U.S. commonwealths or possessions to carry out their tax laws. We may also
disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and
intelligence agencies to combat terrorism. Failure to provide this information may delay or prevent processing your application. Providing false information may subject you to
penalties.
The time needed to complete and submit the foreign account or asset statement will vary depending on individual circumstances. The estimated average time is: 2 hour.
If you have comments concerning the accuracy of this time estimate or suggestions for making the foreign account or asset statement simpler, we would be happy to hear
from you. Comments should be sent to the Internal Revenue Service, Attn: IRS Reports Clearance Officer, SE:W:CAR:MP:T:T:SP, Washington, DC 20224.
11. Please check the box to estimate the range of potential total unreported income from the offshore account(s) during each disclosure
period.
a. Please list all of your accounts for which there is unreported income (attach additional sheets, if necessary)
click to sign
signature
click to edit
click to sign
signature
click to edit
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