Form 14039-B Business Identity Theft Affidavit

Form 14039-B
(May 2021)

Department of the Treasury - Internal Revenue Service

OMB Number
1545-2139

Business Identity Theft Affidavit

Section A – Select One Box
1. I’m not a business owner and haven’t applied for an Employer Identification Number (EIN) but am receiving IRS notices for an
unknown business in my name with an assigned EIN. I’m following the guidance at www.irs.gov/notmyein
The nine-digit EIN I’m reporting is
Complete Sections C, D and F
2. I suspect the business entity, estate, trust, or exempt organization listed in Section B is a victim of identity theft
Complete Sections B, C, D, E and F
Note: Failure to provide required documentation with a signed Form 14039-B may delay processing.

Section B – My Business Information
1. Legal name of entity

2. Approx. date entity established

3. EIN

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

4c. State

5. Tax forms affected

4d. ZIP code

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

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

(if operation ceased, provide tax year/quarter of the final return filed)

9. If your business was not required to file a tax return for the year/quarter you are reporting identity theft, check this box

Section C – Information of Individual Submitting This Form
1. 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)

Not applicable, I checked box 1 in Section A

I am a sole proprietor

I am an officer or director of this corporation/exempt organization

I am a partner

I am the managing member of a multi-member limited liability company

I am the sole member of a limited liability company

I am the Executor, Administrator, Personal Representative, Fiduciary, or Trustee of an estate or trust
Other (describe)
2. Your name

3. Your Taxpayer Identification Number (provide 9-digit SSN or ITIN)

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

5. Your Telephone number (include area code)

Home

Work

Cell

6. Best time(s) to call you

Section D – Reason for Filing this Form (Required)
Provide a brief explanation with relevant dates. If needed, attach additional information and/or pages to this form

Catalog Number 64092C

www.irs.gov

Form 14039-B (Rev. 5-2021)

Section E – Supporting Documentation
1. If known, provide any information you have regarding the person(s) misusing your Employer Identification Number or your name (for
example, provide the alleged perpetrator’s name or address, or copy of a police report). Attach an additional sheet if necessary

2. Supporting Documents
Submit this completed form and a legible photocopy of the document(s) selected below 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 with your signature (e.g., 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, Limited Liability Company, Exempt Organization, Estate or Trust
Send one or more of the documents from the list below
a. Articles of incorporation

b. Articles of organization

c. Trust or estate document

d. A statement signed by an officer or director (not the same person in Section C) on corporate letterhead stationery, stating that the
person in Section C has authority to legally bind the corporation

Section F – Signature
Under penalties 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 person in Section C

Date signed (mm/dd/yyyy)

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 and mail to the address provided on the notice.
• If you did not receive a notice from the IRS, please send this completed form to Internal Revenue Service, Ogden, UT 84201.
2. BY FAX:
• If you received a notice or letter from the IRS related to this issue and it provides a FAX number, you should send this completed form there. If no
FAX number is shown on the notice or letter, please follow the mailing instructions on the notice or letter.
• If you did not receive a notice or letter related to this issue you may FAX this form toll-free to: 855-807-5720. Consider including a cover sheet
marked ‘Confidential’.
3. TAXPAYER ASSISTANCE CENTER:
• If you prefer to submit this form in person at an IRS Taxpayer Assistance Center, you must schedule an appointment by calling toll-free
844-545-5640, Monday through Friday, 7 a.m. to 7 p.m., your local time. At that appointment you will present this completed form with at least one
piece of the required documentation listed above along with your original driver’s license or other valid U.S. Federal or State government issued
photo identification with your signature.
Note: The IRS does not initiate contact with taxpayers by e-mail. Forward IRS-related scam emails to phishing@irs.gov.

Additional Resources
Other helpful identity theft information may be found at www.irs.gov/identitytheft. Additionally, locations and hours of operation for Taxpayer Assistance
Centers can be found at www.irs.gov/localcontacts.
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. For additional information, protection strategies, and resources visit the FTC at www.identitytheft.gov/.

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.

Catalog Number 64092C

www.irs.gov

Form 14039-B (Rev. 5-2021)