Identity Theft Affidavit and Business Identity Theft Affidavit

Forms and Documents

Document Name	Status
Form Form 14039-B Form 14039-B - Business Identity Theft Affidavit Form and Instruction	Modified
Form Form 14039 Form 14039 - Identity Theft Affidavit Form and Instruction	Modified
2019-07-11_SS_1545-2139r.doc Supporting Statement A	2019-07-18

IC Document Collections

IC ID	Document Title	Status
188502	Form 14039-B - Business Identity Theft Affidavit Form and Instruction	Modified
188032	Form 14039 - Identity Theft Affidavit Form and Instruction	Modified

ICR Details

OMB Control No: 1545-2139	ICR Reference No: 201810-1545-004
Status: Active	Previous ICR Reference No: 201510-1545-021
Agency/Subagency: TREAS/IRS	Agency Tracking No:
Title: Identity Theft Affidavit and Business Identity Theft Affidavit
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/06/2019
	Date Received in OIRA: 02/22/2019
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2022	36 Months From Approved	08/31/2019
Responses	402,433	0	100,000
Time Burden (Hours)	514,836	0	25,000
Cost Burden (Dollars)	0	0	0

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Abstract: The primary purpose of these forms is to provide a method of reporting identity theft issues to the IRS so that the IRS may document situations where individuals or businesses 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.

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Authorizing Statute(s): US Code: 26 USC 6001 Name of Law: Notice or regulations requiring records, statements, and special returns
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 47971	09/21/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 4903	02/19/2019
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Form 14039 - Identity Theft Affidavit	Form 14039, Form 14039 (SP)	Identity Theft Affidavit ,   Declaracion Jurada sobre el Robo de Identidad
Form 14039-B - Business Identity Theft Affidavit	Form 14039-B (SP), Form 14039-B	Business Identity Theft Affidavit ,   Declaracion Jurada sobre el Robo de Identidad de un Negocio

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	402,433	100,000	0	0	302,433	0
Annual Time Burden (Hours)	514,836	25,000	0	7,400	482,436	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The reason for change in burden to Forms 14039 and 14039-(SP) are due to an increase in the estimated number of filers from 80,000 to 302,433, which reflected in an increase of burden hours of 402,433. Also, the reason for change in burden to Forms 14039-B and 14039-B(SP) are due to an adjustment in time/per/response from .25 hrs. to .31 hrs. reflecting an increase of 7400 burden hrs.

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Annual Cost to Federal Government: $8,500

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 02/22/2019

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