Department of the Treasury - Internal Revenue Service

Form 14039 OMB Number

(April 2016) Identity Theft Affidavit 1545-2139

Complete this form if you need the IRS to mark an account to identify questionable activity.
Section A - Check the following boxes in this section that apply to the specific situation you are reporting (Required for all filers)
1. I am submitting this Form 14039 for myself
2. I am submitting this Form 14039 in response to a mailed ‘Notice’ or ‘Letter’ received from the IRS. If person in Section C received
IRS ‘Notice CP 2000’, or other IRS Notice questioning income, follow the instructions on that IRS ‘Notice’ or ‘Letter’.
• Please provide ‘Notice’ or ‘Letter’ number(s) on the line to the right
3. I am submitting this Form 14039 on behalf of my dependent.
Please complete Section F on reverse side of this form.
Caution: If you are filing this on behalf of a Minor or Dependent, filing this form will protect his or her tax account but it will not
prevent the dependent in Section C below from being claimed as a dependent by another person.
4. I am submitting this Form 14039 on behalf of another person (other than my dependent).
• Please complete Section F on reverse side of this form.
Section B – Reason For Filing This Form (Required)
Check only ONE of the following boxes that apply to the person listed in Section C below.
1. Federal tax records affected and I am a victim of identity theft
2. Federal tax records not affected and I am a victim of identity theft, or an event has affected/compromised my personal
information placing me at-risk to be a future victim of identity theft.
Please provide an explanation of the identity theft issue, how you became aware of it and provide relevant dates.

Section C – Name and Contact Information of Identity Theft Victim or Potential Victim (Required)
Taxpayer's last name First name Middle initial Taxpayer Identification Number
(Please provide your 9-digit SSN or ITIN)

Current mailing address (apartment or suite number and street, or P.O. Box) If deceased, please provide last known address.

City State ZIP code

Tax Year(s) in which you experienced identity theft (If not known, enter ‘Unknown’ in one of the boxes below) Last tax year a
return was filed

Address used on last filed tax return (If different than ‘Current’) Names used on last filed tax return (If different than ‘Current’)

City (on last tax return filed) State ZIP code

Telephone number with area code (Optional) If deceased, please indicate ‘Deceased’ Best time(s) to call
Home telephone number Cell phone number
Language in which you would like to be contacted English Spanish
Section D – State or Federal Issued Identification (Required)
Submit this completed form and a clear and legible photocopy of at least one of the following documents to verify the identity of the
person listed in Section C above. If necessary, enlarge photocopies so all information is clearly visible.
Check the box next to the document(s) you are submitting:
Driver's license Social Security Card Passport Valid U.S. Federal or State government issued identification**
** Federal employees should not copy his or her employee identification cards as 18 U.S.C. prohibits doing so.
Section E – Penalty of Perjury Statement and Signature (Required)
Under penalty of perjury, I declare that, to the best of my knowledge and belief, the information entered on this Form 14039 is true, correct,
complete, and made in good faith.
Signature of taxpayer, or representative, conservator, parent or guardian Date signed

Catalog Number 52525A www.irs.gov Form 14039 (Rev. 4-2016)

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Section F – Representative, conservator, parent or guardian information (Required if completing Form 14039 on someone else’s behalf)
Check only ONE of the following five boxes next to the reason you are submitting this form
1. The taxpayer is deceased and I am the surviving spouse. (No attachments are required, including death certificate)
2. The taxpayer is deceased and I am the court-appointed or certified personal representative.
Attach a copy of the court certificate showing your appointment.
3. The taxpayer is deceased and a court-appointed or certified personal representative has not been appointed.
o Attach copy of death certificate or formal notification from a government office informing next of kin of the decedent’s death.
o Indicate your relationship to decedent: Spouse Child Parent/Legal Guardian Other
4. The taxpayer is unable to complete this form and I am the appointed conservator or have Power of Attorney/Declaration
of Representative authorization per IRS Form 2848.
o Attach a copy of documentation showing your appointment as conservator or POA authorization.
o If you have an IRS issued Centralized Authorization File (CAF) number, enter the nine-digit number:

5. The victim or potential victim is a ‘minor’. ‘Minor’ as defined per the state in which ‘minor’ resides.
By checking this box and signing below you are indicating that you are an authorized representative, as parent, guardian or legal
guardian, to file a legal document on the child’s behalf.
o Indicate your relationship to minor: Parent/Legal Guardian Fiduciary Relationship per IRS Form 56
Power of Attorney Other
Representative's name
Last name First name Middle initial
Last four digits of Representative’s Taxpayer ID number Representative’s telephone number (include area code)

Representative’s current mailing address (apt., suite no. and street, or P.O. Box)

City State ZIP code

Instructions for Submitting this Form

Submit this to the IRS via Mail or FAX to specialized IRS processing areas dedicated to assist you. In Section C of this form, be sure to include your Social
Security Number or Individual Taxpayer Identification Number in the ‘Taxpayer Identification Number’ field.
Help us avoid delays:
Choose one method of submitting this form either by Mail or by FAX, not both. Please provide clear and readable photocopies. Note that ‘tax returns’ may
not be submitted to either the mailing address or FAX number provided below.

Submitting by Mail Submitting by FAX

• If you checked Box 1 in Section B of Form 14039, are unable to file • If you checked Box 1 in Section B of Form 14039 and are submitting
your tax return electronically because the primary and/or secondary this form in response to a notice or letter received from the IRS that
SSN was misused, attach Form 14039 and documentation to your shows a reply FAX number, FAX completed Form 14039 and
paper tax return and submit to the IRS location where you normally file documentation with a copy of the notice or letter to that number.
your tax return. • Include a cover sheet marked ‘Confidential’. If no FAX number is shown
If you have already filed your paper return, submit this Form 14039 and on the notice or letter, follow the mailing instructions on the notice or letter.
documentation to the IRS location where you normally file. Refer to the • If you checked Box 2 in Section B of Form 14039 (no current tax-
‘Where Do You File’ section of your return instructions or visit IRS.gov and related issue), FAX this form and documentation toll-free to:
input the search term ‘Where to File’. 855-807-5720
• If you checked Box 1 in Section B and are submitting this Form 14039
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
contained in the notice or letter.
• If you checked Box 2 in Section B of Form 14039 (no current tax-
related issue), mail this form and documentation to:
Internal Revenue Service
Fresno, CA 93888-0025

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.

Catalog Number 52525A www.irs.gov Form 14039 (Rev. 4-2016)