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This document is an identity theft declaration form from the New York State Department of Taxation and Finance. It allows victims of identity theft to notify the department and mark their tax accounts for any questionable activity. The form collects information about the taxpayer such as name, address, social security number, tax years affected, and documentation to verify identity such as a driver's license or passport. It directs taxpayers how to submit the completed form and identity verification documents to the department for review.

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131 views

Dtf275 Fill in

This document is an identity theft declaration form from the New York State Department of Taxation and Finance. It allows victims of identity theft to notify the department and mark their tax accounts for any questionable activity. The form collects information about the taxpayer such as name, address, social security number, tax years affected, and documentation to verify identity such as a driver's license or passport. It directs taxpayers how to submit the completed form and identity verification documents to the department for review.

Uploaded by

vikas_ojha54706
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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New York State Department of Taxation and Finance

Identity Theft Declaration

DTF-275

(2/13)

Complete and submit this form if you are an actual or potential victim of identity theft and would like the New York State Department of Taxation and Finance to mark your account to identify any questionable activity. Mark an X in one of the following boxes: I am a victim of identity theft and it is affecting my New York State tax records. I have experienced an event involving my personal information that may at some future time affect my NYS tax records. (Mark this box if you are the victim of non-tax-related identity theft or at risk due to a lost/stolen wallet or purse, questionable credit card or report activity, etc.)

Briefly describe the problem and how you were made aware of it.

Taxpayers last name First name

Middle Last 4 digits of social Document locator number, Assessment ID, or initial security number (SSN) Case ID from our notice (if received)

Taxpayers current mailing address (number and street with apt. or suite no., or PO box) City State ZIP code Telephone #

Home

Work

Cell

Best time(s) to call

I prefer to be contacted in (indicate language)


English Spanish Other:

Tax year(s) affected (if applicable or known)

Tax year and filing status of last NYS tax return filed (if not required to file, enter NRF)

Address on last NYS tax return filed (if same as current address, write same as above) City State ZIP code

Under penalty 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 taxpayer Printed name of person signing Date signed (mm-dd-yyyy)

Submit this completed form and a photocopy of one of the following documents to verify your identity: a) Drivers license b) U.S. passport c) U.S. military ID card d) Other valid ID issued by a state or federal agency You must also include photocopies of the following: Proof of address for tax year(s) affected or, if not applicable, your current address (on utility bill, lease agreement, bank statement, etc.) Notice received from NYS Tax Department (if received) Send the photocopies required above with this form using one of the following options: Fax to: (518) 435-2990 Attn: Identity Theft (This is the preferred method.) or Mail to*: NYS AssEssmEnt RECEiVABLEs ATTN IDENTITY THEFT PO BoX 4128 BinGhAmton NY 13902-4128 *If you are not responding by U.S. Mail, be sure to consult Publication 55, Designated Private Delivery Services.

275001130094

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