TAX RESOLUTION INTAKE QUESTIONNAIRE

TAX RESOLUTION INTAKE QUESTIONNAIRE
SECTION 1: CLIENT INFORMATION
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Filing Status

SingleHead of HouseholdMarried Filing JointlyMarried Filing Separately
SECTION 2: TAX DEBT OVERVIEW
Do you currently owe the IRS?

YesNoNot sure
Estimated amount owed:
What tax years are involved?
How did you find out you owe the IRS?

IRS letterFiled return balanceNot sure
SECTION 3: IRS COLLECTION STATUS
Are you currently experiencing any of the following?

Wage garnishmentBank levyTax lienPassport restrictionPayment plan already in placeNone
Have you received any IRS notices recently?

YesNoNot sure
What type of notice (if known)?
SECTION 4: TAX COMPLIANCE STATUS

This helps determine what options you qualify for
Have you filed all required tax returns?

YesNoNot sure
We will need to complete your filings before resolution.
Have you filed your most recent tax retrurn?

YesNoExtension filed
Are you currently self-employed or earning 1099 income?

YesNo
Are you making estimated tax payments?

YesNo
Have you received notices about unfiled returns or substitute for return (SFR)?

YesNoNot sure
I understand that IRS compliance (filing all required tax returns) is required before any resolution program can be approved.
SECTION 5: INCOME & EMPLOYMENT
Employment Status

W2Self-employedBothUnemployedRetired
Employer Name
Monthly Income: (before taxes)
Do you have additional income?

YesNo
Monthly amount:
Is your income consistent each month?

YesNo
SECTION 6: MONTHLY EXPENSES
Rent/Mortgage:
Utilities:
Food:
Transportation:
Car Payment:
Insurance:
Childcare:
Medical Expenses:
Child Support:
Other Expenses:
SECTION 7: ASSETS
Do you own a home?

YesNo
Value:
Mortgage Balance:
Do you own a vehicle?

YesNo
Vehicles (year/make/model)
Estimated value:
Total money in bank accounts:
Do you have retirement accounts (401k, IRA)?

YesNo
Estimated balance:
SECTION 8: LIABILITIES
Credit Cards:
Total balance:
Monthly payment:
Personal Loans
Total balance:
Monthly payment:
Student loans
Total balance:
Monthly payment:
Child support/alimony:
Total balance:
Monthly payment:
SECTION 9: CLIENT GOALS
What is your main goal?

Lower the balanceRemove penaltiesSet up payment planStop collectionsNot sure
What is your biggest concern right now?
How soon do you want to resolve this?

ASAPWithin 3-6 monthsJust exploring
SECTION 10: EXPECTATIONS & AUTHORIZATION
Type a question

I understand IRS resolution timelines may take several monthsI understand results depends on my financial eligibilityI agree to provide accurate and complete information.
Signature
Date

MonthDayYear
Date
Should be Empty:

TAX RESOLUTION INTAKE QUESTIONNAIRE

SECTION 1: CLIENT INFORMATION

SECTION 2: TAX DEBT OVERVIEW

SECTION 3: IRS COLLECTION STATUS

SECTION 4: TAX COMPLIANCE STATUS

SECTION 5: INCOME & EMPLOYMENT

SECTION 6: MONTHLY EXPENSES

SECTION 7: ASSETS

SECTION 8: LIABILITIES

SECTION 9: CLIENT GOALS

SECTION 10: EXPECTATIONS & AUTHORIZATION