Federal Offshore Voluntary Disclosure Letter

Offshore Voluntary Disclosure Letter
Form 14457 (Rev. 11-2017)
Form

Department of the Treasury–Internal Revenue Service

14457

(November 2017)

OMB Number
1545-2241

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

Submit Form 14457 to: Internal Revenue Service
Voluntary Disclosure Coordinator
1-D04-100
2970 Market Street
Philadelphia, PA 19104
To assist in a timely determination of acceptance into the Voluntary Disclosure Program (for Voluntary Disclosures involving offshore
accounts), the Taxpayer must address all of the following items. All answers and attachments must be in English.
If you filed jointly at any point during the past eight years, your spouse should also apply for the OVDP by answering the
questions below.
Date
1a. Name
Taxpayer

1b. Taxpayer Identification Number
Taxpayer

1c. Date of Birth
Taxpayer

Spouse

Spouse

Spouse

1d. Address
Taxpayer

1e. Telephone number
Taxpayer

Spouse

Spouse

For items 1f through 1k, attach additional sheets, if necessary.
1f. Passport Number(s)
Taxpayer

1g. Country(ies)
Taxpayer

1h. Current Occupation
Taxpayer

Spouse

Spouse

Spouse

1i. Bank Name(s)
Taxpayer

1j. Name on Bank Account
Taxpayer

1k. Bank Account Number(s)
Taxpayer

Spouse

Spouse

Spouse

Note: Estates must include a court document or Form 56 verifying who is authorized to sign the Form 2848.
2a. Taxpayer Representative

2b. Phone Number

2c. Address of Taxpayer Representative
2d. Email address of Taxpayer Representative
3. Type of Voluntary Disclosure

Offshore Only
Offshore and Domestic
4. How did you learn about the Offshore Voluntary Disclosure Program?

5. Identify the Source of Funds
U.S. Wages
Foreign Business Income
a. Explanation

U.S. Business Income

Gift/Inheritance

Illegal Source

Other

Foreign Wages

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 U.S. Government pursuant to an official
request?
Taxpayer
Yes
No
Spouse

Yes

No

a. If “Yes,” did you or anyone on your behalf submit documents in opposition?
Taxpayer

Yes

No

Yes

No

Spouse
Catalog Number 61637F

www.irs.gov

Form 14457 (Rev. 11-2017)

Page 2
b. If “Yes,” were copies of those documents provided to the Attorney General of the United States as required by 18 USC §3506?
Taxpayer
Yes
No
Spouse

Yes

No

7. Disclose if you or any related entities currently under audit or criminal investigation by the Internal Revenue Service or any other law
enforcement authority?
a. Has the IRS notified you, your spouse or any related entities that it intends to commence an examination or investigation?
Taxpayer
Yes
No
Spouse
Yes
No
Related entities

Yes

No

Yes

No

Spouse

Yes

No

Related entities

Yes

No

8. Do you believe that the IRS has obtained information concerning your tax liability?
If “Yes,” specify.

Yes

No

9. During the disclosure period, have you taken a position that you were a bona fide resident of a U.S. territory
(e.g., American Samoa, the Commonwealth of the Northern Mariana Islands, Guam, Puerto Rico, or the U.S.
Virgin Islands) or did you file an income tax return with a U.S. territory?
If “Yes,” list the territory and tax years.

Yes

No

b. Are you, your spouse or any related entities under criminal investigation by any law enforcement authority?
Taxpayer

c. If “Yes,” explain.

10. Please check the box to estimate the annual range of the highest aggregate value of your offshore accounts.
Highest Aggregate
Account/Asset Value

Tax Year

Tax Year

Tax Year

Tax Year

Tax Year

Tax Year

Tax Year

Tax Year

$0 to $100,000
$100,000 to $1,000,000
$1,000,000 to $2,500,000
$2,500,000 to $10,000,000
$10,000,000 to $100,000,000
Greater than $100,000,000
a. Please list all of your accounts (attach additional sheets, if necessary)

Catalog Number 61637F

www.irs.gov

Form 14457 (Rev. 11-2017)

Page 3
11. Please check the box to estimate the range of potential total unreported income from the offshore account(s) during each disclosure
period.
Estimated Total
Unreported Income

Tax Year

Tax Year

Tax Year

Tax Year

Tax Year

Tax Year

Tax Year

Tax Year

$0 to $100,000
$100,000 to $1,000,000
$1,000,000 to $2,500,000
$2,500,000 to $10,000,000
Greater than $10,000,000
a. Please list all of your accounts for which there is unreported income (attach additional sheets, if necessary)

For each foreign financial account of which you have control or are a beneficial owner, complete the attached Form 14454, Attachment
to Offshore Voluntary Disclosure Letter. Please ensure all pages of the attachment include your name, the last four digits of your
taxpayer identification number, the name of the foreign financial institution, and the account number for which you are responding.
To be included with all Forms 14457:
By signing this document, I certify that I am willing to continue to cooperate with the Internal Revenue Service, including in assessing
my income tax liabilities and making good faith arrangements to pay all taxes, interest, and penalties associated with this voluntary
disclosure.
Under penalties of perjury, I declare that I have examined this document, all attachments, and accompanying statements, and to the
best of my knowledge and belief, they are true, correct, and complete.

Signature of Taxpayer

Print Name

Date

Signature of Taxpayer's Spouse

Print Name

Date

Signature must be original (must be mailed), preferably in blue ink. Photocopied, facsimile, or electronic signatures are not
acceptable. The power of attorney may not sign the voluntary disclosure letter on behalf of the taxpayers.
IRS reserves the right to make further contacts with the taxpayer to clarify his/her submission.

Privacy Act and Paperwork Reduction Act Notice
We ask for the information on this foreign account or asset statement to carry out the Internal Revenue laws of the United States. Our authority to ask for information is
sections 6001, 6109, 7801, 7803 and the regulations thereunder. This information will be used to determine and collect the correct amount of tax under the terms of the
offshore voluntary disclosure program. You are not required to apply for participation in the offshore voluntary disclosure program. However, if you choose to apply you are
required to provide all the information requested on the offshore voluntary disclosure letter.
You are not required to provide the information requested on a document that is subject to the Paperwork Reduction Act unless the document displays a valid OMB control
number. Books or records relating to a document or its instructions must be retained as long as their contents may become material in the administration of any Internal
Revenue law. Generally, tax returns and return information are confidential, as required by section 6103. Section 6103, however, allows or requires the Internal Revenue
Service to disclose or give this information to others as described in the Internal Revenue Code. For example, we may disclose this information to the Department of Justice to
enforce the tax laws, both civil and criminal, and to cities, states, the District of Columbia, and U.S. commonwealths or possessions to carry out their tax laws. We may also
disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and
intelligence agencies to combat terrorism. Failure to provide this information may delay or prevent processing your application. Providing false information may subject you to
penalties.
The time needed to complete and submit the foreign account or asset statement will vary depending on individual circumstances. The estimated average time is: 2 hour.
If you have comments concerning the accuracy of this time estimate or suggestions for making the foreign account or asset statement simpler, we would be happy to hear
from you. Comments should be sent to the Internal Revenue Service, Attn: IRS Reports Clearance Officer, SE:W:CAR:MP:T:T:SP, Washington, DC 20224.

Catalog Number 61637F

www.irs.gov

Form 14457 (Rev. 11-2017)