* required fields

Please complete and submit this form if you are an actual or potential victim of identity theft and would like the North Carolina Department of Revenue to mark your account to identify any questionable activity.

* Please check one of the following boxes I am a victim of identity theft and I believe the incident is affecting my tax records      (Provide a short explanation of the tax impact)      I am a victim of identity theft and believe I may be at risk for future impact to my tax account I am a potential victim of identity theft and believe I may be at risk for future impact to my tax account. You should      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.

* Tax year(s) impacted and/or date the incident occurred (if applicable or known) * Last tax return filed (year) (Enter NRF if not required to file)

* Taxpayer's Last Name * Taxpayer's First Name M.I. * Provide the last 4 digits of your Social Security Number (SSN)

* Taxpayer's current mailing address

* City * State * Zip AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA WV WI WY

* Address on last tax return filed (Type "NR" if you are not required to file a tax return)

* City * State * Zip AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA WV WI WY * Telephone     Home    Work    Cell * Email Address * Primary language:      English      Spanish      Other - specify below   * By submitting this form I hereby certify that, to the best of my knowledge, this form is accurate and complete.