IRS REPRESENTATION INTAKE*

Thank you for reaching out to CW's Services for tax representation services. This form helps us understand your situation and gather the details we need to advocate on your behalf with the IRS or state tax authorities. Please provide accurate information so we can assess your case and develop the best strategy for resolution. All information submitted will be kept strictly confidential and used only for your representation.

Section 1: Taxpayer Information

First Name*

Last Name*

Primary Email*

Taxpayer's social security

Spouse First Name, Middle Initial & Last name

Spouse Social Security Number

Home Address (Please include City, State & Zip Code)

Phone

Section 2: Income Information

Are you employed?

Yes

Are you Self-Employed?

Yes

Name of Business

Business EIN Number

Approximate Monthly Income

Do you have retirement accounts ?

Yes

Approximate value?

Section 3: Additional Financial Factors

How Many Dependents Will You Be Claiming?

Do you own a home?

Yes

Plan to retire within the next few years?

Yes

If you had to make a monthly payment to the IRS what amount do you feel comfortable with?

Any serious health issues which may impact income?

Any other life changing events expected in the next 2 years (inheritance, new child, child graduating, care of elderly parent, etc.)?

Section 4: Tax Debt

Are you already in a Payment Plan with the IRS?

Yes

What is your monthly payment amount?

Are you current on your payments?

Yes

When did you last receive a letter from the IRS?

What is the current amount owed?

When was the last time you filed a tax return?

Have you ever received a letter from the State?

Yes

What is your monthly payment amount?

Section 5: Miscellaneous

What worries you the most about your tax debt issues?

Other 2

Would you rather have an affordable monthly payment or a larger lump sum payment?

Affordable Monthly Payment

Lump Sum Payment

Why did you seek my help?

Other

Authorization & Accuracy Confirmation

I confirm that the information provided in this form is true and accurate to the best of my knowledge. I authorize CW's Services to use this information to evaluate my case and represent me before the IRS and/or state tax authorities. I understand that all information will be kept confidential and used solely for the purpose of tax resolution services.