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Printable Form 14039 (SP) Allegheny Pennsylvania: What You Should Know

ID Theft Affidavit — D.C. Form 14039 (Rev. 12-2011). Department of the Treasury. I'd Theft Affidavit. Catalog Number 22550A. OMB Number. . A fillable Form 14039 PDF is available: (1) on IRS.gov (2) via e-mail and (3) via the Electronic Federal Taxpayer Assistance Center (FETAL). The form will cover the following categories of victims that have filed or will file Forms 1009, 1125, 1151, 6051, 7511, 7550 or 7545 claiming a Social Security number: (1) A tax refund fraud victim; (2) A child dependent for whom the parent or other person may be assessed a penalty equal to the tax due for the return due; (3) A taxpayer who has become disabled; (4) A taxpayer who uses or intends to use a Social Security number for fraudulent purposes or, alternatively, the taxpayer does not want to use a Social Security number and requests that the IRS not issue a form for the purpose of using a Social Security number to file a tax return; (5) A taxpayer who is deceased; (6) A taxpayer with a Social Security number who has been granted a leave of absence from work under section 6015; (7) A taxpayer who is a participant in a federal or state Medicaid program; (8) A person who is a non-resident alien, including a U.S. national, citizen or green card holder and is a resident of the United States or a District of Columbia who was granted a visa on or after September 11, 2001; (9) A taxpayer who files Forms 1040-C, 1040-EZ, 1040-INT, 1040A or 1040A-EZ with a Form 1095-F, 1095-EZ, 1095-PR, 1095-SSNR or 1095-SSN. (10) A spouse of a child of a taxpayer with a Social Security number who is dependent on the parent for support; or (11) A victim who is an officer, director, employee or agent of any Federal, State, Local or foreign government (except a foreign government employee or agent acting in his or her official capacity); or (12) A person who knowingly participates in another person's election or attempted election to be a candidate for office under Federal, State, City, or District of Columbia election laws.

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