Form 3949-A Departnent ofthe Treasury = Interal Revenue Service SiiNimbe (October 2020} Information Referral 1545-1960 (See nshuctons cn rev) {Uso is Tor to repor suepeced ta law vclatione by a person oa business CAUTION: READ THE INSTRUCTIONS BEFORE COMPLETING THIS FORM. There may be other more appropriate forms specific to your complaint. (For example, if you suspect your identity was etolen, use Form 14039.) Section A Information About the Person or Business You Are Reporting Compete 7 fyou are reporting an Individual Complete 2, ifyau are reparing a business only. Complete f and 2 Fyou are reporting a business and is owner (Leave biank any thes you dt know) ‘a, Name of india Social Seeunty NuriberTIN & Date of bith Offender Name Here 3 Sirol aadross ©. ity {State [9.2 cote 1234 Their Address Street City / Town st | 12345 i Oeewpaton 1 Ema adress Prosecutor / Judge / Etc. (put their e-mail if you know it) [Marat status oneok one, known Name of spouse ( Mamied [] Single [] Hoadeftousonod [] Divorced [[] Separated 2a, Name of business ©, Emplover TacID number (EN) «. Telephone number BANK / COMPANY / COURT NAME of Yok” sos” wéastine 8 Sot across ©. Gly {State [9.2 cose 1234 THEIR ADDRESS ST. i Email acess i Website (put their e-mail if you know it) (put their website if you know it) Section B — Describe tho Alleged Violation of Income Tax Law 3 Aleged violation of oome fx aw. (Cheek a that apply) i) False Exemption TH Unsubstaniated income LZ) Unreported income C1. Feature to Witinold Tex [False Decuctons (1 Eamed Income Credit [1 Nareotics income [Faure to Fie Return (Matte Filings ( PubiciPoial Coruption Kickback 1) Fature toPay Tax Bl Orgenized Grime [Xl FaiselAterec Documents 1 WagerniGamting IH Otter aescrbe in 9 4 Unreported indore and tak yours Fil in Tax Years and dalla amounts, funawn (eg, TY 2040- $10,000) Ty20208""igie TY Ss vos vos vs wos 5. Comments (Briofy describe the facts of the alleged vilaton-Wha/What/Where/VihervHow you learned about and obtained the infomation in ths report Adach another sheet, needed) See attached. (3949A attachment template) i Aalional information. Answer these quesiions possible, Othenrise, eave Blank a, A bookracords avalabie? (i avatao, do not sond now. Wo wl contact you. thoy are needed for an unvostgoton,) [Yoo No ». Do you consider the taxpayer dangerous HH ves Ol No Banks, Financia Instlutons usod bythe taxpayer Name ‘Name SAME AS ABOVE Siectaddress ‘Sheet adaress iy Site | ZIP code ciy Site | ZIP code Section € — Information About Yourself (We never share iis formation wii the person or business you oF eporing) This inermation ig net requied to process your tape, Bul woul! ba nap we ned ta eanlast yu Tar any ational inormason, 7a. Your name Telephone number |e Besttime to call First Middle Last 3, Shrest across @.Gity Slate g.Z1P cove c/o 1234 Your Address Street City / Town tate [12345] Print and send your completed form tol Calslog Numbor 47872 wer s.g0¥ Form 3949-A (Rev, 10-2020)