0217 Form 14693 (PDF)

Official source: IRS Forms, Instructions & Publications (https://www.irs.gov/pub/irs-pdf/f14693.pdf), retrieved 2026-10-03. U.S. Government work (17 U.S.C. § 105).

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(February 2017)

Department of the Treasury - Internal Revenue Service

OMB Number

1545-2273

Date Form 14693 was sent to claimant (IRS use only)

1. Claimant

a. Name of individual claimant Last First MI

c. Name of spouse (if applicable) Last First MI

b. Claimant TIN (Social Security Number or Individual Taxpayer ID

Number (last four digits only))

d. Spouse's TIN (Social Security Number or Individual Taxpayer ID

Number (last four digits only))

e. Address ( street, city, provence/state, postal/ZIP code, country (if not USA)) f. Claim number(s)

g. Telephone number

2. Name of Attorney Whose Fees Will be Deducted (if applicable)

3. Attorney Fees and Court Costs

a. Amount of deduction for attorney fees and court costs paid or to be paid in connection with an award under section 7623(b), that

claimant intends to claim on a federal income tax return $

b. Are any amounts of the attorney fees paid on a contingency basis (check one) Yes No

4. Attachments to Substantiate Fees and Costs

a. Copy of contingency fee agreement or other fee agreement between the claimant and the claimant's attorney.

b. Copies of bills to substantiate the amount of attorney fees incurred in connection with award under section 7623(b).

c. Copies of bills to substantiate the amount of court costs incurred in connection with award under section 7623(b).

d. Any other information to substantiate a deduction for attorney fees and court costs incurred in connection with an award under

section 7623(b).

Declaration Under Penalty of Perjury

Under penalties of perjury, I declare that I have examined the application, including any accompanying documents, schedules, exhibits, affidavits, and statements and to the best of my knowledge and belief it is true, correct and complete.

Signature of Claimant or Authorized Representative Date

Note: If an Authorized Representative signs this form, provide a valid Form 2848, Power of Attorney and Declaration of Representative, with original signatures.

Send completed form, along with supporting attachments to:

Internal Revenue Service

Whistleblower Office 1111 Constitution Ave., NW Washington, DC 20224

Catalog Number 67566P www.irs.gov Form 14693 (2-2017)

Page 2

Instructions for Application for Reduced Rate of Withholding on Whistleblower Award

Payment, Form 14693

Use this form ONLY if you have been notified that you are due to receive a whistleblower award under Section 7623(b) and you want to reduce the rate of withholding on the award. To be considered for a reduced withholding rate, the application (Form14693) must be received by the Whistleblower Office within 30 days from the date printed on the form.

Please read the instructions before completing the form.

Claimant

1a. Enter the last name, first name, and middle initial of the claimant

1b. Enter the last, first and middle initial of the claimant’s spouse, if applicable

1c. Enter address information

1d. Enter the last four digits of the Claimant’s Identification Number (SSN, ITIN, etc)

1e. Enter the claim numbers

1f. Enter the phone number

Attorney

2a. Enter the last name, first name, and middle initial of the attorney whose fees will be deducted

2b. Enter address information

2c. Enter the phone number

Attorney Fees and Court Costs

3. Enter the dollar amount you intend to deduct on your tax return for (a) Attorney Fees and (b) Court Costs

Attach Documents to Substantiate Attorney Fees and Court Costs

4a. Agreement between claimant and attorney

4b. Bills of attorney fees

4c. Bills of court costs

4d. Other documents to support attorney fees and court costs

Declaration Section

The claimant or his or her authorized representative may sign the declaration statement. This request will not be considered complete or valid if the declaration statement is not signed with an original signature and date. If signed by an authorized representative, provide a valid Form 2848, Power of Attorney and Declaration of Representative, with original signatures and date.

Catalog Number 67566P www.irs.gov Form 14693 (2-2017)