2017 PDF
2017 PDF
2017 PDF
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. This Form 14039 is submitted in response to a ‘Notice’ or ‘Letter’ received from the IRS
• Please provide ‘Notice’ or ‘Letter’ number(s) on the line to the right
• Please check box 1 in Section B and see special mailing and faxing instructions on reverse side of this form.
3. I am submitting this Form 14039 on behalf of my ‘dependent child or dependent relative’
• Please complete Section E on reverse side of this form.
Caution: If filing this on behalf of your ‘dependent child or dependent relative’, filing this form will protect his or her tax account
but it will not prevent the victim 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 child or dependent relative)
• Please complete Section E 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. Someone used my information to file taxes
2. I don’t know if someone used my information to file taxes, but I’m a victim of identity theft
Please provide an explanation of the identity theft issue, how you became aware of it and provide relevant dates.
If needed, please attach additional information and/or pages to this form.
Current mailing address (apartment or suite number and street, or P.O. Box) If deceased, please provide last known address
Tax Year(s) you experienced identity theft (If not known, enter ‘Unknown’ in one box below) What is the last year you filed a
return
Address used on last filed tax return (If different than ‘Current’) Names used on last filed tax return (If different than ‘Current’)
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 – 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
Submit this completed form to either the mailing address or the FAX number provided on the reverse side of this form.
Catalog Number 52525A www.irs.gov Form 14039 (Rev. 4-2017)
Page 2
Section E – 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
• Attach copy of death certificate or formal notification from a government office informing next of kin of the decedent’s death.
• Indicate your relationship to decedent: 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
• Attach a copy of documentation showing your appointment as conservator or POA authorization.
• If you have an IRS issued Centralized Authorization File (CAF) number, enter the nine-digit number: