Suspect's Last Name:

Suspect's First Name:

Suspect's Business/Company Name:

Suspect's Address (Line 1):

Suspect's Address (Line 2):

Suspect's City

Suspect's State

Suspect's ZIP Code

Suspect's Phone Number (include area code)

Suspect's Identification Number (i.e. Federal Employee Identification Number or Social Security Number)

Suspect's Type of Business

What is the possible violation?

Under reporting

Not filing a tax return

Not paying taxes

Other (describe below)
     

What tax type is the possible violation occurring in?

Sales and Use Tax

Business Tax

Corporate Tax

Individual (Hall) Income Tax

Tobacco Tax

Motor Fuel Taxes

Other (list below)
     

When did the suspected violation occur? List known period/years involved

How is the suspected violation occurring? Example: Not charging/not collecting/not paying Sales Tax

How do you know this?

Additional information (List any other information that may be helpful in the investigation):

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Your Last Name:

Your First Name:

Your Address (Line 1):

Your Address (Line 2):

Your City:

Your State:

Your ZIP Code:

Your Phone Number (include area code):

Your e-mail address: