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Click ‘Get Form’ to open it in the editor.
Begin by entering your full legal name in the designated field. Ensure accuracy as this is crucial for identification.
If your account name differs from your legal name, provide that information in the next field.
Input your Social Security Number (SS#) carefully, as this is vital for the investigation.
Enter a phone number where you can be reached during the investigation process.
Fill in your current physical address; note that P.O. Boxes are not acceptable.
If applicable, provide a mailing address different from your physical address.
List any account numbers associated with suspected fraud if known.
Provide details of valid accounts you hold with the bank, including account numbers and types.
Enter your police case number, which is essential for initiating an investigation.
Describe the questionable activity in detail and specify any documents or information you are requesting.
Indicate the date of the application or transaction in question if known.
Provide any additional information that may assist with the investigation.
Authorize the bank to release information as indicated and ensure you sign and date the form. Remember, your signature must be notarized before submission.
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Reporting identity theft | Internal Revenue Service
Dec 4, 2025 Complete Form 14039, Identity Theft Affidavit (in English PDF or Spanish PDF). See the Instructions for Submitting this Form in Form 14039, for informationRead more
Jan 23, 2018 If your SSN has been lost or stolen or you suspect youre a victim of tax-related identity theft, visit please report it to us at IRS.gov/SAMSRead more
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