FTB 3552: California Identity Theft Affidavit

Check one of the following boxes: I am a victim of identity theft, and I believe this incident is affecting my tax account. Provide a short explanation of the tax impact.

I am a victim of identity theft, and I believe I may be at risk for future impact to my tax account. I am a potential victim of identity theft, and I believe I may be at risk for future impact to my tax account.

Check “potential victim” if you have not experienced identity theft but are at risk due to a lost/stolen purse or wallet, questionable credit card or credit report activity, etc.

Fill in Taxable Year(s) Impacted (if applicable or known), Date the Incident Occurred (if applicable or known) and Last Tax Return Filed (Year). Enter NRF if Not Required to File.

Provide the last 4 digits of your Social Security Number or your complete Individual Taxpayer Identification Number.

Fill in Last Name, First Name, Middle Initial, Current Mailing Address, City, State and ZIP Code.

Fill in Address on Last Tax Return Filed with City, State and ZIP Code. Check Here If You Are Not Required to File a Tax Return.

Fill in Telephone Number and mark Home, Work or Cell, then fill in Best Time (s) to Call. For Primary Language mark English, Spanish or Other and fill in Specify.

Under penalty of perjury, I declare that, to the best of my knowledge and belief, the information entered in this form is true, correct, complete, and made in good faith. I hereby agree and consent that the facsimile/fax signature of this affidavit shall be considered as valid as the original.

Submit this completed form and a copy of at least one of the following documents to verify your identity.

Check the box next to the document you are submitting: a) Passport, b) Driver license or Department of Motor Vehicles identification card.

If available, include a copy of: c) Social security card, d) Police report, e) Internal Revenue Service letter of determination.

Submit the copies required above with this form using one of the options described on PAGE 2 of this form.

If you received a notice from FTB, return this form with a copy of the notice to the address contained in the notice.

If you have not received an FTB notice and are self-reporting potential risk for future impact to your tax account, mail this form to: FILING COMPLIANCE BUREAU MS F151 FRANCHISE TAX BOARD PO BOX 1468 SACRAMENTO CA 95812-1468 If you received a notice in the mail from FTB and a fax number is shown, fax this completed form with a copy of the notice to that number.

Include a cover sheet marked “Confidential.” If no fax number is shown, follow the mailing instructions.

If you have not received an FTB notice and are self-reporting potential risk for future impact to your tax account, fax this form to: 916.843.0561