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Offshore Voluntary Disclosures

If taxpayer has domestic issues only, please have them apply for a traditional voluntary disclosure.

Date:      

Internal Revenue Service

Voluntary Disclosure Coordinator

1-D04-100

2970 Market Street

Philadelphia, PA 19104

Re: Taxpayer Name      

Tax Identification Number      

Taxpayer Date of Birth      

Taxpayer Address      

Dear Voluntary Disclosure Coordinator:

To assist in a timely determination of my acceptance into the Voluntary Disclosure Program, (for Voluntary Disclosures involving offshore accounts), I have addressed all of the following items:

1. Please include:

o Complete name:      

o Social Security Number:      

o Date of Birth:      

o Address:      

o Passport Number (and Country):      

o Current Occupation:      

2. Taxpayer Representative and his/her contact information.

3. Type of Voluntary Disclosure

Offshore Only Offshore and Domestic

4. Identify the source of the funds.

5. Have any of the offshore accounts you are disclosing been identified by the IRS as ineligible for this program?

Yes No

6. Has anyone, including a foreign government or a foreign financial institution, advised you that your offshore account records, which are the subject of this voluntary disclosure, were susceptible to being turned over to the US Government pursuant to an official request?

Yes No

o If yes, did you or anyone on your behalf submit documents in opposition?

Yes No

o If yes, were copies of those documents provided to the Attorney General of the United States as required by 18 USC § 3506?

Yes No

7. Disclose if you or any related entities...