Contact Us

Name *

Address #1

Address #2

City		State		Zip Code

Phone (Day)		Phone (Evening)

Fax		Email Address *

Size of federal tax debt (approximate)

Type of tax returns for which you are liable
(e.g., 1040, 1120, 940, 941, etc.)

Tax years for which you are liable

Have you received any mailed notices from the IRS?

Were those tax returns filed? If so, when?
(those for which you owe)

Have you been personally contacted by any IRS agent?

Do you have state tax debts or other debts?

If so, in what amount?

Please state whether you own any of the following assets. If you own such an asset, provide its approximate value as reduced by any mortgage, loan, or other encumbrance. Do not include any leased or rented item.

Home		Vehicle

Boat		Bank Accounts

Retirement Accounts		Real Property

Gross Monthly Income?

Comments - Best time to contact, questions, etc.

Privacy Statement:
The information which you give in completing this form will be forwarded to the designated party for its use and will not be used by YELLOWPAGES.COM for any other purpose or provided by us to any other parties. If you wish information concerning the privacy policy or the designated recipient, you should contact them directly.

* Required to submit this form