ONLINE FORM Information regarding the IRS Impersonation Scam(s) you wish to report :
Date of Incident:
 Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
 Year
2018
2017
2016
2015
2014
2013
2012
2011
Did you suffer a financial loss?
Yes No
If Yes , enter amount:
$
How did you pay the impersonator?

iTunes Card
Amazon
eBay
Credit Card
Debit Card
Personal Check
Bank Check
Green Dot/MoneyPak
REloadit
Target Gift Card
Western Union
Cash
MoneyGram
Walmart Money Transfer
No Payment
Other
If Other , enter method:
Where did you go to make your payment?

Walmart
Target
CVS
Ace Cash Express
Walgreens
Rite Aide
Giant
Safeway
Other
If Other , enter location:
Your Payment City:
Your Payment State:

Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Virgin Island
Washington
West Virginia
Wisconsin
Wyoming
Payment Date:
 Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
 Year
2018
2017
2016
2015
2014
2013
2012
2011
Time:
Dollar Amount Provided:
Name of Person Payment Sent To:
Sent to City:
Sent to State:

Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Virgin Island
Washington
West Virginia
Wisconsin
Wyoming
Bank Account Number:
Bank Name:
Routing Number:
If you provided a Second Payment:
On the second payment, how did you pay the impersonator?

iTunes Card
Amazon
eBay
Credit Card
Debit Card
Personal Check
Bank Check
Green Dot/MoneyPak
REloadit
Target Gift Card
Western Union
Cash
MoneyGram
Walmart Money Transfer
No Payment
Other
If Other , enter method:
Where did you go to make your payment?

Walmart
Target
CVS
Ace Cash Express
Walgreens
Rite Aide
Giant
Safeway
Other
If Other , enter location:
Your Payment City:
Your Payment State:

Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Virgin Island
Washington
West Virginia
Wisconsin
Wyoming
Payment Date:
 Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
 Year
2018
2017
2016
2015
2014
2013
2012
2011
Time:
Dollar Amount Provided:
Name of Person Payment Sent To:
Sent to City:
Sent to State:

Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Virgin Island
Washington
West Virginia
Wisconsin
Wyoming
Bank Account Number:
Bank Name:
Routing Number:
Did you provide the impersonator with any personal or sensitive information (other than your full name, telephone number or address)?
Yes No
If, Yes , please specify the type of information:
If you provided your Date of Birth, please enter it here:
MM DD YYYY
If you provided your Social Security Number, please enter it here:
Please confirm Social Security Number
How did the impersonator contact you?
Email
Fax
Mail
Mobile Phone
Landline
In person
How did the caller identify himself/herself (name and/or title)?
From what phone number did they contact you?
From what email address did they contact you?
What phone numbers were you directed to call?
Additional Information (Optional): Limit 500 characters
Please enter your name, address, city, state of residence, ZIP code, e-mail address, and/or your telephone number below. This will assist us if we need to get in touch with you for additional information.
Name:
Street Address:
City of Residence:
State of Residence:

Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Virgin Island
Washington
West Virginia
Wisconsin
Wyoming
ZIP Code:
Email Address:
Telephone:
Cell Telephone:
Date of Birth:
MM DD YYYY
Social Security Number:
(Optional) Last 4 Digits
Please create a 5-digit verification PIN. You will not be able to submit an online complaint without entering a PIN. Please memorize your personalized PIN.
5-digit PIN:
In the event a TIGTA Special Agent contacts you about your complaint, please request the personalized PIN for confirmation. Please take caution if the person does not know the PIN.
*Please memorize and write down your 5-digit PIN before you click the Submit button
Signature (Please Type Your Name):
Signature Date:
 Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
Year
2017
2018
2019
Certify
By checking this certify box and submitting this form, I certify, under penalty of perjury under the laws of the United States of America, that the foregoing is true and correct.
This question prevents automated submissions:
Thank you for filing your complaint. Once you click the submit button, your complaint will be logged; and you may or may not be contacted by our team for follow-up.