IRS Debt Assessment

Contact Information
First Name		Last Name
Middle Initial		Age
Sex	Select Male Female No Answer	Marital Status	Select Single Married Divorced Domestic Partnership
Street Address 1		Street Address 2
City		State
Zip Code
Home Phone		Alternate Phone
E-Mail Address

Tell us about your situation
What type of tax do you owe?	Select Personal Income Business Income Business Payroll Taxes
Approximately how much do you owe?
For what years are these taxes owed?
Have you been contacted by a Revenue Officer?	Select Yes No
How you entered into a payment arrangement?	Select Yes No
Has the IRS filed a lien or notice of lien?
Has the IRS garnished your wages?
Has the IRS levied your bank accounts?
Do you have any un-filed tax returns?	Select Yes No
If yes to the question above, please describe

General Information

Employment Status	Select Un-employed Retired Disability Income Self-employed Employed-1099 Employed-W2
Have you experienced any of the following in the last 12 months? (check all that apply)	Illness Loss of job Family Death Divorce Substance Abuse
	Other

Do you have any other special circumstances that contributed to you not paying the tax owed on time?

Payment Information

Billing Information
Name (As it appears on credit card) *
Type of card *	Visa Master Card Discover
Card Number *
Expiration Date *
Security Code *