Alabama Identity Theft Affidavit

Identity Theft Affidavit
Form INV ID1
ALABAMA DEPARTMENT OF REVENUE
INVESTIGATIONS DIVISION

Form INV ID1
Revised July 2017

P.O. BOX 11487 Huntsville, AL 35814
Phone: (256) 837- 2319

SUBMIT FORM

IDENTITY THEFT AFFIDAVIT

Please complete and submit this form if you are an actual or potential victim of identity theft and would like the Alabama Department of Revenue (ADOR) to
mark your account to identify any questionable activity.
Please check one of the following boxes
_____ I am a victim of identity theft and I believe the incident is affecting my tax records. (Provide a short explanation of the tax impact.)

_____ I am a victim of identity theft and believe I may be at risk for future impact to my tax account
_____ I am a potential victim of identity theft and believe I may be at risk for future impact to my tax account. (You should check "potential victim" if you have not experienced
identity theft but are at risk due to a lost/stolen purse or wallet, questionable credit card or credit report activity, etc.
Tax year(s) impacted and/or date the incident occurred (if applicable or known)

Taxpayer's:

Last name

Last tax return filed (year) (Enter NRF if not required to file)

First name

Middle Initial Provide the last 4 digits of your
Social Security Number (SSN)

Taxpayer's current mailing address

City

State

ZIP code

Address on last tax return filed (Type "NR" if you are not required to file a tax return)

City

State

Telephone Number:

Primary language:

ZIP code

Home/Work/Cell

English

Spanish

Email Address

Other - specify below

Under penalty of perjury, I declare that, to the best of my knowledge and belief, the information entered in this form is true, correct, complete, and made in good faith.

______________________________________________________
(Signature of taxpayer)

__________________________________________
(Date signed mm/dd/yyyy)

Please submit this completed form and a photocopy of at least one of the following documents to verify your identity. (Check the box next to the document you are submitting.)

Driver's license

Non Driver ID

Social Security Card

Passport