Form 14039-B Form 14039-B Business Identity Theft Affidavit

Department of the Treasury - Internal Revenue Service

Form 14039-B

OMB Number
1545-2139

Business Identity Theft Affidavit

January 2014

Complete and submit this form if you suspect that your business entity, estate, trust or exempt organization has been a victim of
identity theft. If you never applied for an Employer Identification Number but have begun receiving notices for a business in your name
check the box in Section A-9 below and complete Sections C and D.
Note: Failure to provide required documentation with a signed and notarized Form 14039-B may delay processing.
Section A – My Business Information
1. Legal name of entity

2. Approx. date entity established 3. Employer Identification Number (EIN)

4a. Current business address (apt., suite no. and street, or P.O. Box)
4b. City

4c. State

5. Tax forms affected

6. Tax year(s)/quarter(s) affected

4d. ZIP code

7. Date final return filed (if applicable)

8. Previous names this entity was known by (if applicable)
9. Check only ONE of the following four boxes
This EIN is currently Active (in business)
This EIN is currently Not Active

(Enter date operation ceased)

I did not apply for an EIN (Complete Sections C and D ONLY)
This EIN is used for "non-tax" purposes only

10. If you were not required to file a tax return for the year/quarter you are reporting identity theft, check this box
Section B – Reason for filing Form 14039-B
1. Confidential business information has been used without my consent. I believe this incident is affecting the tax records of this entity.
Provide a detailed explanation of the identity theft incident. Attach an additional sheet if necessary to fully explain your identity theft
problem.

2. What is your position with the business entity/exempt organization shown below
(You must have the legal authority to act for the entity and to receive return information per IRC 6103)
I am an officer or director of this corporation/exempt organization

I am a sole proprietor

I am the sole member of a limited liability company

I am a partner

I am the managing member of a multi-member limited liability company
I am the executor, Administrator, Personal Representative, Fiduciary, Trustee of an estate or trust
Other (describe)
Section C – Personal Information of Individual Submitting this form
Complete if you are the officer/director for the business entity, estate, trust, exempt organization, or individual.
1. Your name

2. Social Security Number

3. Your mailing address

4. Your mailing address (if different from your business address)

5. Telephone number (include area code)

Form

14039-B (1-2014)

Home

Catalog Number 64092C

Work

Cell

www.irs.gov

6. Best time(s) to call

Department of the Treasury - Internal Revenue Service

Department of the Treasury - Internal Revenue Service

Form 14039-B

OMB Number
1545-2139

Business Identity Theft Affidavit

January 2014

Section D – Signature, Notarization and Supporting Documentation
1. Under penalty of perjury, I declare that, to the best of my knowledge and belief, the information entered on this form is true, correct,
complete, and made in good faith.
Signature of persons authorized to act for this entity
Date signed (mm/dd/yyyy)
2. Select option A or option B
A. Submit this completed form. Signed, stamped and dated by a notary public.

Signature of notary public

My commission expires

Date signed (mm/dd/yyyy)

B. Submit this form along with a copy of police report indicating you are a victim of identity theft

3. Provide any information you have regarding the person(s) misusing your Employer Identification Number or your name (if known).
(For example, provide the alleged perpetrator’s name or address, or copy of a police report). Attach an additional sheet if necessary.

4. Supporting Documents
Submit this completed form and a legible photocopy of the document(s) identified to verify your identity.
Note: Failure to provide a complete form and legible photocopies could result in a delay in processing your request.
(Check the box next to the documents you are submitting. The documentation required is dependent upon the type of entity as
indicated below).
Sole Proprietor: Two documents are required
a. Passport, Driver's license, or Other valid U.S. Federal or State government issued identification (For example - Visa)**
b. Copy of a utility bill, invoice, mortgage/rent receipt or other documentation to support business operation.
** Do not submit photocopies of federally issued identification where prohibited by 18 U.S.C. 701 (e.g., official badges designating federal employment).

Corporation, Partnership Company, Exempt Organization, or Trust:
Send one document from the list below along with Copy of CP575, Notice of EIN Assignment.
a. Articles of incorporation

b. A written statement by the officer or director on corporate letterhead stationery,
to the effect that he/she has authority to legally bind the corporation

c. Articles of organization

d. Trust or estate document

Individual who did NOT apply for an EIN: Send one document as proof of personal identification.
a. Passport, Driver's license, or Other valid U.S. Federal or State government issued identification (For example - Visa)**
** Do not submit photocopies of federally issued identification where prohibited by 18 U.S.C. 701 (e.g., official badges designating federal employment).

Section E – Submitting Form 14039-B
1. BY MAIL: If you received a notice from the IRS, attach Form 14039-B to the back of the notice. If no notice was received, send to the address where
your tax returns are filed.
2. TAXPAYER ASSISTANCE CENTER: If you prefer to go into a taxpayer assistance center, you must present this notarized form
with at least one piece of the required documentation listed above along with an original driver’s license or other federal or state
issued picture ID.
NOTE: The IRS does not initiate contact with taxpayers by e-mail.

Additional Resources
Other helpful identity theft information may be found on www.irs.gov (keyword "identity theft"). Additionally, locations and hours of operation for Taxpayer
Assistance Centers can be found at http://www.irs.gov/localcontacts/index.html.
Note: The Federal Trade Commission (FTC) is the central federal government agency responsible for identity theft awareness. The IRS does not share
taxpayer information with the FTC. Please refer to the FTC's website at http://www.ftc.gov (keyword "identity theft"). For additional information, protection
strategies, and resources.
Privacy Act and Paperwork Reduction Notice
Our legal authority to request the information is 26 U.S.C. 6001.
The primary purpose of the form is to provide a means for reporting the theft of your identity to the IRS. The information requested by this form will allow the IRS to more efficiently assist you in resolving
federal tax issues caused by the theft and will allow the IRS to take actions to protect your account identity in the future. The information is also used to determine your correct tax liability, and whether
you are due a refund or whether any federal taxes are owed.
Providing the information on this form is voluntary. However, if you do not provide the information it may be more difficult to assist you in resolving your identity theft issue. If you intentionally provide false
information, you may be subject to criminal penalties.
You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a
form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as
required by section 6103.
Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. If you have comments concerning the accuracy of these time estimates or suggestions for making this form
simpler, we would be happy to hear from you. You can write to the Internal Revenue Service, Tax Products Coordinating Committee, and SE: W: CAR: MP: T: T: SP, 1111 Constitution Ave. NW, IR-6526,
and Washington, DC 20224. Do not send this form to this address. Instead, see the form for filing instructions.
Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be subject to a penalty for failure to comply with, a collection of information subject to the
requirements of the Paperwork Reduction Act, unless that collection of information displays a currently valid OMB Control Number.

Form

14039-B (1-2014)

Catalog Number 64092C

www.irs.gov

Department of the Treasury - Internal Revenue Service