Client Information

First Name *

Last Name *

Date of birth *

Phone *

Email *

Social Security Number (SSN) *

Address

Street Address *

City *

State *

Country *

Postal Code *

IRS / Tax Issues

Do you owe the IRS? *

Yes

No

Have you received IRS letters? *

Yes

No

Estimated amount owed (if know) *

I certify that the information provided is true and complete to the best of my knowledge

Client Signature *

Date Signed *

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