Federal Identity Theft Affidavit

Identity Theft Affidavit
Form 14039 (Rev. 9-2023)
Form

14039

Department of the Treasury - Internal Revenue Service

OMB Number
1545-2139

Identity Theft Affidavit

(September 2023)

This affidavit is for victims of identity theft. To avoid delays do not use this form if you have already filed a Form 14039 for this incident.
Form 14039 can also be completed online at https://apps.irs.gov/app/digital-mailroom/dmaf/f14039/.
The IRS process for assisting victims selecting Section B, Box 1 below is explained at irs.gov/victimassistance.
Get an IP PIN: We encourage everyone to opt-in to the Identity Protection Personal Identification Number (IP PIN) program. If you don’t have an IP PIN, you
can get one by going to irs.gov/ippin. If unable to do so online, you may schedule an appointment at your closest Taxpayer Assistance Center by calling
(844-545-5640). Or, if eligible, you may use IRS Form 15227 to apply for an IP PIN by mail or FAX, also available by going to irs.gov/ippin.

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 an IRS Notice or Letter received
• Provide ‘Notice’ or ‘Letter’ number(s) on the line to the right
• 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 (include that person’s information below in Section C and D)
• Complete Sections A-F of this form. Do not use this form If dependent’s identity was misused by a parent or guardian in filing taxes, this is not
identity theft.
4. I am submitting this Form 14039 on behalf of another person living or deceased (other than my dependent child or dependent relative)
• Complete Sections A- F of this form.

Section B – How I Am Impacted (required when reporting misuse of Social Security Number (SSN) or Individual Taxpayer Identification Number (ITIN))
Check all boxes that apply to the person listed in Section C below. If the person in Section C has previously submitted a Form 14039 for the same incident,
there’s no need to submit another Form 14039.
1. I know or suspect that someone used my information to fraudulently file a federal tax return
I/My dependent was fraudulently/incorrectly claimed as a dependent (use that person’s information for Section C & D)
My SSN or ITIN was fraudulently used for employment purposes
Note: If you are a victim of Identity theft but it does not involve your federal tax return, you should request an IP PIN to protect yourself. Get An Identity
Protection PIN | Internal Revenue Service (irs.gov)
Provide an explanation of the identity theft issue, how it impacts your tax account, when you became aware of it and provide relevant dates. If needed,
attach additional information and/or pages to this form

Section C – Name and Contact Information of Identity Theft Victim (required)
Victim’s last name

First name

Middle
initial

Taxpayer Identification Number
(provide 9-digit SSN or ITIN)

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

State

ZIP code
-

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

City (on last tax return filed)

State

ZIP code
-

Best time(s) to call

Telephone number with area code. The IRS may call you regarding this affidavit
Home phone number
Language in which you would like to be contacted

Cell phone number
English

Spanish

Other

Section D – Tax Account Information: Last tax return filed (year shown on the tax return) and Returns Impacted (Do not complete
Section D if you selected Box 2 in Section B above)
I was not required to file a return or filed a return with no income information
Names used on last filed tax return

The last tax return filed (year shown on the tax return)

What Tax Year(s) you believe were impacted by tax-related identity theft (example: 2020 is input for citing the 2020 tax return though filed the next
year(s). (if not known, enter ‘Unknown’ below))

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. 9-2023)

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

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
• 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 I have been authorized to act on behalf of the
taxpayer per Form 2848, Power of Attorney and Declaration of Representative
• Attach a copy of documentation showing your appointment as conservator or Power of Attorney authorization.
• If you have an IRS issued Centralized Authorization File (CAF) number, enter the nine-digit number:
5. The person listed above is my dependent child or my dependent relative
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 dependent’s behalf.
• Indicate your relationship to person
Parent/Legal Guardian
Power of Attorney
Fiduciary per IRS Form 56, Notice of Fiduciary Relationship
Other
Parent’s/Representative's name
Last name

First name

Middle initial

Parent’s/Representative’s current mailing address (city, town or post office, state, and ZIP code)
Parent’s/Representative’s telephone number

Instructions for Submitting this Form
Submit this completed and signed form to the IRS via Online, Mail or FAX to specialized IRS processing areas dedicated to assist you.
In Section C of this form, be sure to include the Social Security Number in the ‘Taxpayer Identification Number’ field.
Help us avoid delays:
• Do not use this form if you have already filed a Form 14039 for this incident.
• Choose one method of submitting this form either Online (preferred method), by Mail, or by FAX, not all methods.
• Provide clear and readable photocopies/images of any additional information you may choose to provide.
• Submit the original tax return to the IRS location where you normally file your tax return. Do not use the following address or fax number to file an
original tax return.

Online (Preferred Method)

Submitting by Mail

• https://apps.irs.gov/app/digital-mailroom/dmaf/f14039/

• If you checked Box 2 in Section A in response to a notice or letter
received from the IRS, return this form and if possible, a copy of the
notice or letter to the address contained in the notice or letter.

Submitting by FAX
• Always include a cover sheet marked "Confidential”.
• If you checked Box 2 in Section A of Form 14039 and are submitting
this form in response to a notice or letter received from the IRS. If it
provides a FAX number, you should send there.
• If no FAX number is shown on the notice or letter, follow the mailing
instructions on the notice or letter.
• For all others, FAX this form toll-free to:
855-807-5720

• If you checked Box 1 or 2 in Section B of Form 14039 and are unable
to file your tax return electronically because the SSN/ITIN of you,
your spouse, or dependent was misused, attach this Form 14039 to
the back of your paper tax return and submit to the IRS location where
you normally file your tax return.
• All others should mail this form to:
Department of the Treasury
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. 9-2023)