Department of Taxation and Finance

                                              Identity Theft Declaration                                                       DTF-275
                                                                                                                                                 (5/16) 

Complete and submit this form if you are an actual or potential victim of identity theft and would like the New York State (NYS)
Department of Taxation and Finance to mark your account to identify any questionable activity.
Mark an  Xin one of the following boxes:

     I am a victim of identity theft and it is affecting my NYS 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.

Taxpayer’s 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)

Taxpayer’s current mailing address (number and street with apt. or suite, 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) Driver’s 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 Verification Unit                 or      Mail to: IDENTITY VERIFICATION UNIT
(This is the preferred method.)                                                          PO BOX 4128
                                                                                         BINGHAMTON NY 13902-4128

                                                                                 If you are not using U.S. Mail, see Publication 55,
                                                                                 Designated Private Delivery Services.
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