Declaration under Penalty of Perjury. For joint or multiple claimants. Form 211 must be signed by each claimant. NW IR-6406 Washington DC 20224. Send the completed Form 211 to the above Ogden address of the Whistleblower Office. Telephone number including area code 26. Email address 27. Declaration under Penalty of Perjury I declare that I have examined this application all accompanying statement and supporting documentation and to the best of my knowledge and belief they are true correct and complete Signature of Claimant Catalog Number 16571S Date www.irs.gov Form 211 Rev. 7-2018 Page 2 Instructions for Form 211 Application for Award for Original Information General Information The Whistleblower Office has responsibility for the administration of the whistleblower award program under section 7623 of the Internal Revenue Code. M/S 4110 Ogden UT 84404 Question 1 If you have not previously submitted a Form 211 regarding the same or similar non-compliant activities or the taxpayer s identified in this information have no known relationship to the taxpayer s identified in a previously submitted Form 211 check the box for new submission. If you are providing additional information regarding the same or similar non-compliant activities and are identifying additional noncomplaint activities by the same taxpayer s check the box for supplemental submission. If you are identifying additional taxpayers involved in the same or similar tax non-compliance identified on a previously submitted Form 211 and those additional taxpayers are related to the taxpayer s identified on a previously submitted Form 211 check the box for supplemental submission. If this is supplemental information list previously assigned claim number s. A claimant must file a formal claim for award by completing and sending Form 211 Application for Award for Original Information to be considered for the Whistleblower Program. Send completed form along with any supporting information to Internal Revenue Service Whistleblower Office - ICE 1973 N. Rulon White Blvd. Form OMB Number 1545-0409 Department of the Treasury - Internal Revenue Service Date Claim received Application for Award for Original Information July 2018 Claim number completed by IRS Section A Information About the Person or Business You Are Reporting 1. Is this New submission or Supplemental submission If a supplemental submission list previously assigned claim number s 2. Last 4 digits of Taxpayer Identification Number s e.g. SSN ITIN or EIN 3. Name of taxpayer include aliases and any related taxpayers who committed the violation 4. Is this New submission or Supplemental submission If a supplemental submission list previously assigned claim number s 2. Last 4 digits of Taxpayer Identification Number s e*g* SSN ITIN or EIN 3. Name of taxpayer include aliases and any related taxpayers who committed the violation 4. Taxpayer s address including ZIP code 5. Taxpayer s date of birth or approximate age 6. Name and title and contact information of IRS employee to whom violation was first reported if known 7.
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