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Mo. gov Visit http //dor. mo. gov/personal/individual/identitytheft. php for additional information. Form 5593 Revised 03-2015. Form Reset Form Missouri Department of Revenue Identity Theft Declaration Print Form Complete and submit this form if you are an actual or potential victim of identity theft and would like the Missouri Department of Revenue to mark your account to identify any questionable activity. Select one of the following boxes r I am a victim of identity theft and it is affecting my Missouri state tax records. r I have experienced an event involving my personal information that may at some future time affect my Missouri state tax records. Select this box if you are a victim of non-tax-related identity theft or at risk due to lost or stolen wallet or purse questionable credit card or credit report activity etc* Description of Problem Briefly describe the problem and how you were made aware of it. Last Name First Name Middle Initial Last four digits of social security number X X X - X X - Taxpayer Information Current Mailing Address City Telephone Number State Best Time to Call Zip Code Tax Year s Affected if known - Tax year and filing status Single Married Filing Combined etc of last Missouri tax return filed* If you are not required to file a return enter N/A. Address on last Missouri tax return filed if same as current address write same as above Signature Under penalties of perjury I declare that the above information and any attached supplement is true complete and correct. Signature of Taxpayer Printed Name Date MM/DD/YYYY Submit this completed form a copy of your police report if applicable and a photocopy of one of the following documents to verify your identity to the address or fax number listed below. a Driver s License b U*S* Passport Mail to Taxation Division Attn Identity Theft P. O. Box 3366 Jefferson City MO 65105-3366 c U*S* Military ID Card d Other valid ID issued by a state or federal agency Phone 573 751-3505 Fax 573 751-2195 E-mail idtheft dor. Form Reset Form Missouri Department of Revenue Identity Theft Declaration Print Form Complete and submit this form if you are an actual or potential victim of identity theft and would like the Missouri Department of Revenue to mark your account to identify any questionable activity. Select one of the following boxes r I am a victim of identity theft and it is affecting my Missouri state tax records. Select one of the following boxes r I am a victim of identity theft and it is affecting my Missouri state tax records. r I have experienced an event involving my personal information that may at some future time affect my Missouri state tax records. r I have experienced an event involving my personal information that may at some future time affect my Missouri state tax records. Select this box if you are a victim of non-tax-related identity theft or at risk due to lost or stolen wallet or purse questionable credit card or credit report activity etc* Description of Problem Briefly describe the problem and how you were made aware of it.

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