Tax Debt Bankruptcy Discharge Eligibility Intake Form

Full Name

First NameLast Name

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Mailing Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Which type of bankruptcy have you filed or are considering filing?

For which tax years do you owe federal or state income tax debt? (Select all that apply)

When did you file the tax returns for the debts listed above? (approximate dates are acceptable)

Have you made any payments or entered into a payment plan for these tax debts in the last 240 days?

Have you been assessed any penalties for fraud or willful evasion related to these tax debts?

Are there any tax liens currently filed against you for these debts?

Please provide any additional information you believe is relevant to your tax debt or bankruptcy situation.