Derecho

Form 3949 (2-2007)

A

Department of the Treasury – Internal Revenue Service

Information Referral
(See instructions on reverse)

OMB # 1545-1960

1. Taxpayer Name a. Street Address b.City/State/ZIP c. Social Security Number (SSN) d. Occupation e. Date of Birth 3. Marital Status Married Divorced

2. Business Name a. Street Address b. City/State/ZIP c. Employer Identification Numberd. Principal Bus Activity

3a. Name of Spouse Single Separated Head of Household

4. Alleged Violation of Income Tax Law (Check all that apply). False Exemption False Deductions Multiple FilingOrganized Crime Unsubstantiated Income Kickback False/Altered Documents Failure to Pay Tax Unreported Income Narcotics Income Public/Political Corruption Failure to File Return Failure to Withhold TaxWagering/Gambling Earned Income Credit Other (Describe below)

5. Unreported Income and Tax Years (Fill in Tax Years and dollar amount(s), if known, e.g., TY2005 $10,000) TY $ TY $ TY $ TY $ TY $ TY$

a. Comments (Briefly describe the facts of the alleged violation - Who/What/Where/When/How. Attach another sheet, if needed).

b. Are books/records available? Yes No d. Banks, FinancialInstitutions used by the taxpayer: Name: Address: City/State/ZIP:

c. Do you consider the taxpayer dangerous? Yes No Name: Address: City/State/ZIP:

e. Please describe how you learned and/or obtained theinformation in this report (Attach another sheet, if needed):

6. Your Name: a. Address: b. City/State/ZIP: c. Telephone Number (Please include the Area Code): For Mailing Address, see InstructionsFor Paperwork Reduction Act, see Instructions

Catalog Number 47872E

Form 3949 A (Rev. 2-2007)

Instructions
Provide the following information for the Person/Business You Are Reporting ifKnown: 1. Name a. Street Address of Residence b. City, State, and Zip Code c. Social Security Number d. Date of the Person’s Birth 3. Indicate Martial Status M - Married S - Single HH - Head of...