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Y IRS) 1. Name of individual claimant 2. Claimant's Date of Birth 3. Claimant's SSN or ITIN 4. Name of spouse (if applicable) 5. Spouse's Date of Birth Month Month Day Day Year Year 6. Spouse's SSN or ITIN 7. Address of claimant, including zip code, and telephone number 8. Name & Title of IRS employee to whom violation was reported 9. Date violation reported: 10. Name of taxpayer (include aliases) and any related taxpayers who committed the violation: 11. Taxpayer Identification N.

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