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Form 14039 Identity Theft Affidavit

Catalog Number 14039 (Rev. 4-2017)Form 14039 (April 2017)Department of the Treasury - internal revenue ServiceIdentity Theft AffidavitOMB Number 1545-2139 Complete this form if you need the IRS to mark an account to identify questionable 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 myself2. 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 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.

Catalog Number 52525A. www.irs.gov Form . 14039 (Rev. 4-2017) Form . 14039 (April 2017) Department of the Treasury - Internal Revenue Service. Identity Theft Affidavit

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