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Form

14039

(April 2016)

Department of the Treasury - Internal Revenue Service

OMB Number
1545-2139

Identity Theft Affidavit

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 de