Department of Revenue
Richard H. Roberts, Commissioner

* Suspect's Business/Company Name:

* Suspect's Last Name:

Suspect's First 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?
Please choose from one of the following options:

Under reporting of taxes

Not filing a tax return

Not paying taxes

Other (describe below)

* What tax type(s) is the possible violation occurring in?

Sales and Use Tax

Business Tax

Corporate Tax

Individual (Hall) Income Tax

Tobacco Tax

Motor Fuel Taxes

Other state taxes (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):

OPTIONAL CONTACT INFORMATION: Your submission is ANONYMOUS unless you provide your contact information. We do not receive your e-mail address.

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: