Form 14039 (April 2017) Department of the Treasury - Internal Revenue Service Identity Theft Affidavit OMB Number 1545-2139 Complete this form if you need the IRS to mark an account to identify questionable activity. Section A - Check the following boxes in this section that apply to the specific situation you are reporting (Required for au filers) K 1. I am submitting this Form 14039 for myself K 2. This Form 14039 is submitted in response to a 'Notice' or 'Letter' received from the IRS • Please provide 'Notice' or 'Letter' number(s) on the line to the right • Please check box 1 in Section Et and see special mailing and faxing instructions on reverse side of this form. K 3. I am submitting this Form 14039 on behalf of my 'dependent child or dependent relative' • Please complete Section E on reverse side of this form. Caution: If filing this on behalf of your 'dependent child or dependent relative'. filing this form will protect his or her tax account but it will not prevent the victim in Section C below from being claimed as a dependent by another person. K 4. I am submitting this Form 14039 on behalf of another person (other than my dependent child or dependent relative) • Please complete Section E on reverse side of this form. Section B — Reason For Filing This Form (Required) Check only ONE of the following boxes that apply to the person listed in Section C below. K 1. Someone used my information to file taxes K 2. I don't know if someone used my information to file taxes, but I'm a victim of identity theft Please provide an explanation of the identity theft issue. how you became aware of it and provide relevant dates. If needed. please attach additional information and/or pages to this form. Section C — Name and Contact Information of Identity Theft Victim (Required) Victim's last name First name Middle initial Taxpayer Identification Number (Please provide 9.cfigit Social Security Number) Current mailing address (apartment or sui