Deparment of he Treasury - Intemal Revenue Senco ‘OMB Number 15450409 Form 211 Application for Award for be) (Juy 2018) ‘Glam number (completed by IRS) Original Information Section A — Information About the Person or Business You Are Reporting Tistns [x] New submssonor [_] Supplemental submission Last 4 digts of Taxpayer Ween I supplemental submission, ist previously assigned clam number(s) Numbers) (eg, SSN IT or EN) 3. Name of taxpayer (nude atlases) nd any related taxpayers who commited te vclaton 4 Taxpayers adaress, nluding ZIP code ‘5 Taxpayers date of bith or approximate age {6 Name and tile and contac information of IRS employee fo whom voltion was frst reported, known 7 Aloged Violation of Tax Law (oheckal tat apy 0 treome Tax Employment Tax CO Estate 8 cit Tax ) Texxompt Bonds J Empioyeo Ptans TB Govemmental Entios _Exompt organizations O bese 1 Other toni. {8 Describe the Alleged Violation, State al portent facs to the alleged violation. (tach a detated explanation and ncude all sparing wfomnaton in your possession and desobe the avaisbity and locaton of any aditona supporting fomation natin your possession.) Explain why you believe the act described Constitutes a violation ofthe lax avs 19. Describe how you amed about andr oblained the information that suppors ths Gaim: (lack sheet needed) 10. Whats your rolatonshp(aurent an fame to tho aloged noncompliant axpayoqs)? Check al ha apply. (Atach set nde) 1 Curent Employee 1 Fomer Employee CO Atiomey Copa 1 Retetwerramiy Member [7] Other eserbe) 11. Doyou sil maintain a relationship with he taxpayer [-] Yes L] No 12. yes to number 1, describe you relationship withthe taxpayer {5 you invlved wih any oovermmental orlogal proceadng ivowna he payer LJ Yes [] No 14 yes to nanber 13, plain in dtl Ach sheet needa 46, Desenbe the amount of tax owed bythe taxpayer(s). Provide a summary ofthe information you have that supports your claim as tothe amount owed (ie books, ledgers, records, ects, ax retuns, ee). (Atach sheet W needed) 46 Fin Tax Year (TY) and Dollar Amount (8), known Y s Y 5 Y s Y 8 Y s Section B — Information About Yourself 17. Name of individual aimant 18, Clamants date ofbith @ANOOYYYY) | 19, Last 4 dgis of Claimant's SSN or TIN 20. re you current an RS employes [_] Yes [_] No] 21. Are you tho spouse ora dependent of aniRS employes] Yes [|] No 22. ee you current an RS contractor [_] Yes [] No] 23. Are you a Fedora, Sate or Local Goverment employee [_] Yes [] No 24, Aakress of lament, ncudng ZIP code 25, Telephone number finding we code) 26, Email adcress 27. Declaration under Penalty of Perjury | decare that have examined ths application, all accompanying slatement and supporting documentation, and, to the best of my knowledge and belie, they are ue, corect, and compete ‘Signature of Camant Date (Catalog Numbor 165715 wars gov Form 211 (Rev. 72018)Page 2 Instructions for Form 211, Application for Award for Original Information ‘General Information: The Whistleblower Office has responsibiliy for the administration of the whislablower award program under section 7623 of the Internal Revenue Code. Section 7623 authorizes the payment of awards from the proceeds of amounts the Government collects as a result ofthe information provided by the whistleblower. A claimant must file a formal claim for award by ‘completing and sending Form 211, Application for Award for Original Information, to be considered for the Whistleblower Program, ‘Send completed form along with any supporting information to: Internal Revenue Service Whistleblower Office - ICE 4973 N. Rulon White Blvd, MWS 4110, (Ogden, UT 84404 instructions for Completion of Form 241: ‘Question 1 If you have not previously submitted a Form 211 regarding the same or similar non-compliant activities, or the taxpayers) identified in this information have no known relationship to the taxpayer(s) identified in a previously Submitted Form 211, check the box for ‘new submission.” I you are providing additional information regarding the same or similar non-compliant activities, and are identiying additional non- ‘complaint activities by the same taxpayer(s), check the box for “supplemental submission.” If you are identifying additional taxpayers involved in the same or similar tax non-compliance identified on a previously submitted Form 211, and those additional taxpayers are related to the taxpayer(s) identified on a previously submitted Form 211, check the box for ‘supplemental submission.” I this is supplemental information, lst previously assigned caim number(s). ‘Questions 2 - 5 Information about the Taxpayer ~ Provide the taxpayer's name, addr (if known), and the taxpayer's date of birth or approximate age. taxpayer identification number last 4 digits ‘Question 6 If you reported the violation to an IRS employee; please provide the employee's name, te and the date the violation was reported. f known, provide contact information. ‘Questions 7 ~8 Indicate the type of tax that has not been paid or the tax liabilty that has not been reported and describe the alleged violation. Explain why you beliove the act described constitutes a violation of the tax laws. Attach all supporting documentation (for ‘example, books and records) to substantiate the claim. If documents or supporting evidence are not in your possession, describe these documents and their location. ‘Questions 9 - 14 These questions ask how and when you leamed of the alleged violation and what relationship, if any, you have to the taxpayer. ‘Questions 15 ~ 16 These questions are asking for an estimate of the tax owed and the years/periods that the tax applies, ‘Questions 17 — 26 Information about the claimant — Provide the claimant's name, address, date of birth, SSN or ITIN (last 4 digits), ‘email address, and telephone number. ‘Question 27 Information provided in connection with a claim under this provision of law must be made under an original signed Declaration under Penalty of Perjury. For joint or multiple claimants. Form 211 must be signed by each claimant Privacy Act and Paperwork Reduction Act Notice ‘We ask forthe formation on this form to cary out he intarnalrevenve laws ofthe Unied Stats. Our author fo ask fortis information = 26USC 6109 and 1623. We colect ts infomation for use in determining te corect amount of any award payable to you under 26 USC /623, We may disclose ths information {2 authored by 26 USC 6103, including toe subject taxpayers) as needed in a tax compliance investigation and to the Deparment of Justi for cv and ‘criminal ibgation. You are not required to apply for an award. However, you apply for an award you must provide as much of he requested information as possible. Falute to provide information may delay or proven processing your request for an award, providng fase information may subject you to pene. ‘You ar not requred to prove the information requested ona form thats subject othe Paperwork Reduction Act uniess the form dsplays a vai OMB contol number: Books oF records relating toa form or ifs struchons must be retained as long as fer contents may become material in he adminstaon of ‘any internal revenue law. Generally, tax returns and return information ae confidential, as required by 26 U.S.C 6103, “The ime needed to complet ths form wil vary depending on individual ckcumstances. The estimated average time is 45 mines. H you have comments {concerning te accuracy ofthese time estimates or suggestions for making this fom simpler, we would be happy to hear fiom you. You can email us at “taxfoms@irs gov (please type ‘Forms Comment” on the subject ine) or wrt io the Iniernai Revenve Service, Tax Forms Coordinating Commitee, SE. W- CAR MP. T-T SP, 1111 Consttubon Ave. NW, IR-6400, Washinglon, DC 20224 Sond te completed Fox 211 tothe above Ogden address ofthe Whistleblower Offco. Do NOT send the Fam 211 tothe Tax Forms Coordinating Commit Catalog Numbor 165715 ‘wi iS gO Form 211 (Rev. 72018)