FORM # 4a
TAX PROBLEM STATUS
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Who is filling out this form?
Taxpayer's spouse or other relative
Enrolled agent or CPS
Single - never married
Married and living together
Married but living apart
Formerly married - spouse deceased
Taxpayer's E-mail Address
Taxpayer's preferred Phone Number
Preferred way to Contact?
Taxpayer is represented by:
Tax help person
Attorney's name, phone number, and email address
Enrolled Agent's name, phone number, and email address
Filed you filed bankruptcy
Filed and finished
Filed and still in bankruptcy
Never filed bankruptcy
Thinking about filing bankruptcy
Have you at any time:
Did a CDP - Collection Due Process appeal
Applied for an offer-in-compromise
Litigated a tax issue in U.S. Tax Court
Been audited by the IRS and assessed additional taxes
Been in "non-collectible status"
Failed to file a tax return?
Filed a tax return late?
Appealed anything to a higher venue?
Been ruled an innocent spouse
Charged with tax fraud or evasion?
Plead to or found guilty of tax fraud or evastion?
What kind of taxes do you owe?
IRS personal income taxes
IRS payroll taxes
State personal income taxes
State payroll taxes
IRS tax penalties
State tax penalties
Restitution for tax offense
Liens & Levies
Tax entity has recorded liens on your property
No tax liens have been filed
Taxpayer owns no property of value
Taxpayer owns real estate
There is a tax levy currently in effect
There are no levies in effect
Are you currently being audited?
Are there any unfiled IRS tax returns? If yes, what tax years are missing returns.
Are there any unfiled state tax returns? If yes, what years?
Have you at any time:
Filed or been accused of filing a fraudulent tax return
Attempted or been accused of tax evasion
Charged with or been accused of any other tax crime
Lied to any IRS person?
Assaulted or attempted to assault a tax officer
Tried to hide assets
Transferred title to anything to a minor?
Transferred title to a spouse, friend, business associate, family member
Deposited money in a friend's or family member's bank account
Deposited money in an off-shore bank account
Forged any tax or financial documents
Filed a lien against a tax officer
Deposited property or money into a trust
Deposited property or money into a close corporation
Purchased property in someone else's name
Lost, concealed, or destroyed financial records
Sold or traded valuable assets for less than fair value
Lived a "lavish lifestyle" while owing back taxes
Changed banks frequently to avoid levies
Changed your name, social security number, or similar documents
Been a member of a tax protest organization
For which tax years or periods do you owe? Identify
Upload documents relevant to your problem (Max 35 pages)
Why did you not pay taxes?
Losses due to fire, theft, or other similar events
Explain other reasons for not paying taxes
Why did you fail to file one or more returns?
Do you presently have a court hearing or an IRS hearing coming up? If so, when is it calendared for?
Have you been notified or served with a tax action that you must reply or respond to?
Yes - criminal charges - fraud or evasion
Yes - Notice of Deficiency
Yes - reply to audit
Yes - IRS claim in bankruptcy
Other pending matter
Deadline to reply or file:
Has the tax person seized or is holding any of your money or property? Describe:
Are there other issues that King should know about?
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