Business Information

Full Legal Name of the Business:

Type of Business:

Legal Structure: —Please choose an option—S CorporationC CorporationNon_Profit or Tax ExemptPartnershipSole ProprietorshipLLC-Limited Liabilty

Mailing Address line one:

Suite or Internal Mail Stop/Code:

City:

State:

Zip code:

Business Telephone with Extension:

Private Telephone with Extension:

Business Cellular Phone:

Personal Information

Salutation: —Please choose an option—Mr.Mrs.MissPartnershipSole ProprietorshipMs.

First Name:

Last Name:

Email:

Business Title:

Mailing Address:

Suite or Apartment:

City:

State:

Zip code:

Home Telephone:

Cellular Telephone:

Telefax:

Type of tax owed: —Please choose an option—Unfilled PersonalUnpaid BusinessUnpaid PayrollTaxes assessed by IRSOther

What years are Involved:

Approximate Amount: —Please choose an option—$1,000 ~ $15,000$15,000 ~ $25,000$25,000 ~ $50,000$50,000 ~ $100,000$100,000 or More

The best time to contact: —Please choose an option—Weekdays Morning 9:00Weekdays Afternoon 12:00Weekdays Evening 6:00Saturday 10:00 to 5:00

Please contact me by: —Please choose an option—Office TelephonePrivate Business TelephoneBusiness CellphoneHome TelephonePersonal Cellphone

I have been audited

I have been levied through My bank AccountI have been levied through My Payroll Earnings

I have not filed my tax returns

I have not received notices of levies and/or lien

Additional Information