) Fill in the name of the secure and verifiable document. Print, complete, sign, and notarize the Download this pdf file.Instructions to Applicants to the M.D. program: This is a fillable PDF form. Please answer the following questions within the space. This affidavit is for victims of identity theft. To avoid delays do not use this form if you have already filed a Form 14039 for this incident. Instructions: To be filled out and submitted with payment of Occupation Tax.