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Pennsylvania Identity Theft Affidavit
Extracted from PDF file 2023-pennsylvania-form-rev-1196.pdf, last modified March 2016Identity Theft Affidavit
(EX) 11-18 REV-1196 OFFICIAL USE ONLY BurEau of IndIvIdual taXEs fraud dEtEctIon and analysIs unIt Po BoX 280607 HarrIsBurg, Pa 17128-0607 IDENTITY THEFT AFFIDAVIT Please complete and submit this form if you are a victim of tax related identity theft and would like the Pennsylvania Department of Revenue to open an identity theft claim and place a fraud trigger on your account to review for possible fraudulent activity. SECTION I PERSONAL INFORMATION Fill out all boxes with information of the identity theft victim. START Tax Year(s) Impacted and/or Date the Incident Occurred (If applicable or known.) Last PA Tax Year Return Filed (If not required to file, enter NRF.) ➜ YYYY DLN (if applicable)(located on letter) Last 4 Digits of SSN Case Number (if already assigned) Taxpayer’s Name Taxpayer’s Current Street Address City State ZIP Code State ZIP Code Street Address on Last PA Tax Return Filed City Daytime Telephone Number SECTION II Home Work cell Best time(s) to Call QUESTIONNAIRE Answer all questions “YES” OR “NO”. Provide details and documents to support your claim if required. 1. Did you file an identity theft report with the police? yes (please send copy of report) no (please explain) 2. Did you request that a fraud alert be placed on your credit report? yes no (please explain below) 3. Have you reported this to the Social Security Administration? yes no (please explain below) 4. Have you reported this to the IRS? yes (please send copy of Irs form 14039) no (please explain below) 5. I am aware of fraudulent tax returns filed with the following: PA-40 (please list all years affected) IRS 1040 (please list all years affected) Other States (please specify) Reset Entire Form TOP OF PAGE NEXT PAGE PRINT SECTION III IDENTITY THEFT EXPLANATION (Attach another sheet, if needed.) Provide a detailed explanation of how your identity may have been compromised and how your tax account may be affected. SECTION IV CERTIFICATION 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. Name Signature Telephone Number Email Address SIGN AFTER PRINTING Title Date MMDDYYYY Reset Entire Form PREVIOUS PAGE NEXT PAGE PRINT Pennsylvania Department of Revenue Instructions for REV-1196 rEv-1196 In (EX) 11-18 Identity theft affadavit GENERAL INFORMATION UNAWARE OF STATUS Please complete and submit this form if you are a victim of tax related identity theft and would like the Pennsylvania Department of Revenue to open an identity theft claim and place a fraud trigger on your account to review for possible fraudulent activity. If you are submitting this form because you have been a victim of Identity Theft but are not sure if your Pennsylvania tax account has been affected, mail this completed form (REV1196) to the address listed below. You may also email this completed form to [email protected] or fax it to 717-705-4614. PA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES FRAUD DETECTION AND ANALYSIS UNIT PO BOX 280607 HARRISBURG, PA 17128-0607 IN RESPONSE TO A LETTER If you are submitting this form in response to a letter from the Pennsylvania Department of Revenue regarding an identity theft case, mail or fax this completed form (REV1196) and any additionally requested documents along with a copy of the letter that you received to the address or fax number indicated on the initial letter. REJECTED RETURN If you are submitting this form because your electronic PA40 Personal Income Tax return was rejected because of a filing already with the Pennsylvania Department of Revenue, mail this completed form (REV-1196) along with a signed copy of your PA-40 return, a copy of your government issued photo ID with current address, and a copy of your Social Security Card to the address listed below. You may also email all of this information to [email protected] or fax it to 717-705-4614. PA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES FRAUD DETECTION AND ANALYSIS UNIT PO BOX 280607 HARRISBURG, PA 17128-0607 www.revenue.pa.gov PREVIOUS PAGE REV-1196 RETURN TO FORM 1
Identity Theft Affidavit (REV-1196)
More about the Pennsylvania Form REV-1196 Other TY 2023
We last updated the Identity Theft Affidavit in February 2024, so this is the latest version of Form REV-1196, fully updated for tax year 2023. You can download or print current or past-year PDFs of Form REV-1196 directly from TaxFormFinder. You can print other Pennsylvania tax forms here.
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TaxFormFinder has an additional 174 Pennsylvania income tax forms that you may need, plus all federal income tax forms.
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| Form PA-1000 RC | PA Rent Certificate - PA Rent Certificate and Rental Occupancy Affidavit (PA Property Tax/Rent Rebate) |
| Form REV-1176 | E-TIDES Administrative Access Change Request Form |
| Form REV-181 | Application for a PA Tax Clearance Certificate |
View all 175 Pennsylvania Income Tax Forms
Form Sources:
Pennsylvania usually releases forms for the current tax year between January and April. We last updated Pennsylvania Form REV-1196 from the Department of Revenue in February 2024.
Historical Past-Year Versions of Pennsylvania Form REV-1196
We have a total of two past-year versions of Form REV-1196 in the TaxFormFinder archives, including for the previous tax year. Download past year versions of this tax form as PDFs here:
2023 Form REV-1196
Identity Theft Affidavit (REV-1196)
2022 Form REV-1196
Identity Theft Affidavit (REV-1196)
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