KRA-IMF001
KRA-IR001

ISO 9001:2008 CERTIFIED KENYA REVENUE AUTHORITY INFORMER MANAGEMENT FORM

CONFIDENTIAL Ref. No: Date:

Information Referral
(See instructions on reverse)

1. Taxpayer Name a. Street Address b. Town c. Personal Identification Number (PIN) d. Occupation 3. Alleged Tax Violation. (Check where appropriate). False Exemption False Deductions Refund fraud Organized Crime Unsubstantiated Income Kickback/corruption False/Altered Documents Failure to Pay Tax

2. Business Name/ Trading name a. Street Address b. Town c. PIN/ID/Certificate of incorporation d. Principal Business Activity

Unreported Income Smuggling Income Electronic system fraud Failure to File Return

Failure to Withhold Tax Diversion of goods Undervaluation Other (Describe below)

4a. Comments (Briefly describe the facts of the alleged violation - Who/What/Where/When/How. Including details of directors and any principal person(s) involved in the evasion. Attach another sheet, if needed).

b. Are books/records available? Yes No Not aware d. Banks, Financial Institutions used by the taxpayer: Bank Name: Account No:

c. Do you consider the taxpayer dangerous? Yes No Not aware

e. Please describe how you learned and/or obtained the information in this report (Attach another sheet, if needed):

6. Informer Name: Contact Address: Date: Signature: 5. Name of officer receiving information: Title: Comments:

Identification Number: Telephone number: Next of kin details Employment number: Work Station:

Signature:

Date and time:

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(Back page) Instructions
Please note that the reward is awarded at the discretion of the Commissioner General Provide the following information for the Person/Business You Are Reporting if Known: 1. Name a. Street Address of Residence b. Town c. Personal Identification No. d. Date of the Person’s Birth 2. Business Name a. Street Address of Business b. Town b. Enter Employer Identification Number d. Describe the Primary Business Activity 3. Check all Tax Violations That Apply to Your Report or Describe in Comments If Not Listed. 4. a. Briefly describe the facts of the alleged violation(s) as you know them. Please attach another sheet, if you need more room. b. Indicate (Yes or No) if books and/or records are available that substantiate your report. c. Indicate (Yes or No) if you consider the person to be violent or dangerous and provide an explanation in the comments section of this form. d. List name and address of bank(s) and/or financial institution(s) used by the taxpayer if known. e. Briefly explain how you learned of or obtained the information contained in your report. Please attach another sheet, if you need more room. 5. Enter your name, contact address, identification number, telephone number where you can be contacted. Indicate your next of kin appropriately.

Please print and send your completed form to the Complaints Information centre Kenya Revenue Authority 30th Floor Times Tower P.O. Box 48240 -00100 Nairobi Or any KRA office near you

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