Form 8821-A IRS Disclosure Authorization for Victims of Identity The

OMB No. 1545-1165

Form

8821-A

April 2012
Department of the Treasury
Internal Revenue Service

For IRS Use Only

IRS Disclosure Authorization
for Victims of Identity Theft

Received by:
Name
Telephone
Function
Date

Taxpayer Information
Taxpayer name

Social Security Number

Daytime telephone number

State

ZIP code

Taxpayer mailing address
City

Tax year
Enter the tax year for which your return, and any purported return, was filed. If there are
additional years, you must complete and submit another Form 8821-A for each year.

Taxpayer Consent
I,

, consent for the Internal Revenue Service to disclose to
(Name of taxpayer)

, of
(Name and Title of recipient official)

,
(Name of State/Local law enforcement agency)

(Phone number)

,
(Street address of State/Local law enforcement agency (street, city, state, ZIP code))

any information related to the processing of my return, or any purported return that may have been filed by a third party using my name
and/or social security number without my knowledge or consent, for the tax year listed above. This information includes the return I
filed, any purported return filed by a third party, communications between myself and IRS personnel and any other information gathered
or generated by the IRS in the processing of my return or any purported return, including the IRS's determination that such return was
not my return. This information would not include the identity of, or any investigatory information regarding, the person(s) who may
have filed the purported return.
I understand that the state or local law enforcement agency designated above may use this information to investigate and/or prosecute
any person(s) who may have been involved in the filing of the purported return or other crimes related to the use of my identifying
information. I further understand that the state or local law enforcement agency designated above may share this information with other
law enforcement agencies directly involved in this or other investigations and/or prosecutions of crimes related to the use of my
identifying information by these persons.

Taxpayer Signature
I certify that I am the taxpayer whose name and/or social security number was used to file my return, or any purported return. If signed
by a guardian, executor, receiver, administrator, trustee or party other than the taxpayer, I certify that I have the authority to sign this
form with respect to this matter.
Note: Do not sign this form if it is blank or incomplete. The IRS will only accept forms with original signatures.
Signature
Print name
Date signed
IRS regulations require that this disclosure authorization be received by the IRS within 120 days of the date that it is signed by the
taxpayer.

Privacy Act and Paperwork Reduction Act Notice
We ask for the information on this form to carry out the Internal Revenue laws of the United States. This form authorizes the IRS to disclose your
confidential tax information to the person/agency you appoint. This form is provided for your convenience and its use is voluntary. The information is
used by the IRS to determine what confidential tax information your appointee can inspect and/or receive. Section 6103(c) and its regulations require
you to provide this information if you want to appoint a designee to inspect and/or receive your confidential tax information. Under section 6109, you
must disclose your social security or other taxpayer identification number. If you do not provide all the information requested on the form, we may not be
able to honor the authorization. Providing false or fraudulent information may subject you to penalties. We may disclose this information to the
Department of Justice for civil or criminal litigation, and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in
administering their tax laws. We may also disclose this information to other countries under a tax treaty, to Federal and state agencies to enforce
Federal non-tax criminal laws, or to Federal law enforcement and intelligence agencies to combat terrorism.
The time needed to complete and file this form will vary depending on individual circumstances. The estimated average time is 9 minutes. If you have
comments concerning the accuracy of these time estimates or suggestions for making Form 8821-A simpler, we would be happy to hear from you. You
can write to Internal Revenue Service, Tax Products Coordinating Committee, SE:W:CAR:MP:T:M:S, 1111 Constitution Ave. NW, IR-6526, Washington,
DC 20224. Do not send Form 8821-A to this address.
Catalog Number 59482M

Form

8821-A (4-2012)

Instructions for Form 8821-A, IRS Disclosure Authorization for Victims of Identity Theft
General Instructions
This form is available only from IRS Criminal Investigation or state/local law enforcement agencies, as appropriate.
Purpose of Form
This form is an authorization signed by the taxpayer allowing the IRS to disclose the taxpayer's return, any purported return, and other
related return information to state or local law enforcement in the event of possible identity theft. It may not be used for any other
purpose.
When To File
The IRS must receive Form 8821-A within 120 days of the date it is signed and dated by the taxpayer. The IRS will consider forms
received after 120 days invalid.
Where To File
The taxpayer will return the completed form to IRS Criminal Investigation or to state or local law enforcement as directed by the person
who provided the form.
Social Security Number (SSN)
Social Security Numbers are used to identify taxpayer information with tax returns. It is important that you furnish the correct name and
SSN, so that the IRS can respond to your request.

Specific Instructions
Taxpayer Information
Enter the taxpayer's name, SSN, and street address.
Tax Year
Enter the tax year for which the taxpayer's return and any purported return was filed. If there are additional years, you must complete
and submit another Form 8821-A for each year.
Taxpayer Consent
Enter taxpayer name in the space provided. Enter the full name and title of the state or local law enforcement official to whom the
described taxpayer information may be provided, as well as the name, address, and telephone number of the state or local law
enforcement agency.
Taxpayer Signature
Sign and date the authorization. The IRS will only accept forms with original signatures.

Catalog Number 59482M

Form

8821-A (4-2012)