Contact information

Washington DC Address: Executive Office Headquarters 1025 Connecticut Ave., NW, Suite 1012 Washington DC 20036	New York Address: 2 Penn Plaza, Suite 1500 New York, NY 10121-0088 (212) 292-4970	HOME ABOUT US
Virginia Address: 9667 Main Street, Suite B Fairfax, VA 22031	Phone: (888) 712-7690 Fax: (703) 425-1567 E-Mail: info@irstaxattorney.com

The information provided in this form is protected by attorney-client privilege.Under no event is this information shared with a third party. Please provide as much information as possible for accurate assessment of your case.

Name
Daytime Phone no. Evening Phone no.
Email address

Street Address
City

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Preferrable way of contact: Email Phone

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Is the IRS garnishing your wages? Yes No	Has the IRS recently levied your bank account(s)? Yes No
Are you currently going through a bankruptcy? Yes No	Are you currently under IRS audit examination? Yes No
Do you have any unfiled tax returns? Yes No Unsure	Total amount of tax liability:
You are: Single Married Divorced/Seperated Widowed	Is your spouse assessed with the tax liability? Yes No Unsure
The liability is in: Your name The name of your business Both Someone you know	What is your net monthly income, after deductions and taxes? ( An estimate is fine)
What is your spouse's net monthly income, after deductions and taxes? ( An estimate is fine)	How many people are in your household?

How old are you?	Do you have a major health problem? Yes No
Is anyone depended on you having a major health problem? Yes No	Outline the health problem:
Do you or your spouse own a real estate? If yes: What is the Fair Market Value? The amount of unpaid mortgage?	Do you or your spouse own any retirement plan such as an IRA or 401(k)? If yes: What is the total amount? Amount borrowed against 401(k), if applicable?
Do you have a tax lien? Yes No Are you interested in removing the lien to buy or refinance realestate? Yes No	Did you use a search engine to find us? If yes: Search engine used: Search term used:

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