Name:

________________________________________

Spouse's name (if you file jointly):

________________________________________

Address:

________________________________________

Telephone numbers (home, work, cell, pager):

________________________________________

Social Security Number:

________________________________________

Spouse's SSN (if you file jointly):

________________________________________

Date of birth:

________________________________________

Employment status:

________________________________________

Annual salary (to help determine your tax liability):

________________________________________

Other sources of income:

INFORMATION ABOUT YOUR TAX DISPUTE

Please provide copies of your tax returns from the last three years, plus returns, correspondence and documentation involved in your dispute.

Are you being audited? __Y/__N
If yes, please describe the basis for the audit (to the best of your knowledge):

Have you ever been audited in the past? __Y/__N
If yes, please describe how the audit was resolved (including any payment arrangements):

Are you facing another IRS action other than an audit? __Y/__N
If yes, please describe:

Are you pursuing a dispute with the IRS? __Y/__N
If yes, describe your complaint in as much detail as possible, providing dates and indicating whether you have supporting documentation (please provide copies):

Have you filed a formal complaint with the IRS? __Y/__N
If yes, please describe and provide documentation:

Has your complaint been disposed of by the IRS? __Y/__N
If yes, what was the outcome of the proceedings?

Did you complain to anyone at the IRS informally? __Y/__N
If so, what was the response to your complaint?

What is your desired outcome?