First Name:
Last Name:
Email:
City:
State:
Choose
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Home Phone:
Work Phone:
Best Time to Contact:
Morning
Afternoon
Evening
Estimated Total (They Claim Owed):
Choose
$5,000-$7,499
$7,500-$9,999
$10,000-$19,999
$20,000-$29,999
$30,000-$39,999
$40,000-$49,999
$50,000-$59,999
$60,000-$69,999
$70,000-$79,999
$80,000-$89,999
$90,000-$99,999
$100,000-$199,999
$200,000-$299,999
$300,000-$399,999
$400,000-$499,999
$500,000-$599,999
$600,000-$699,999
$700,000-$799,999
$800,000-$899,999
$900,000-$999,999
$1,000,000 +
Please rate your credit:
Choose
Excellent
Good
Fair
Poor
(You must have at least $7500 in tax debt to qualify.)
Amount of Credit Card Debt:
Choose
$0 - $4999
$5000 - $5999
$6000 - $6999
$7000 - $7999
$8000 - $8999
$9000 - $9999
$10000 - $14999
$15000 - $19999
$20000 - $24999
$30000 - $34999
$35000 - $39999
$40000 - $44999
$45000 - $49999
$50000 or more
Do you own or rent?
Choose
Own
Rent
Brief Description of you Tax Problem:
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