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Nationwide Tax Relief

If you require urgent assistance, please call 1-800-750-7500 for a free confidential consultation. Our tax professionals will immediately put a halt to ongoing or impending IRS actions.

1) Please fill out this section COMPLETELY:

* = required field

General Information

*First Name:
*Last Name:
Company:
Address:
Address:
City:
State/Province: (Choose One) Alabama Alaska Alberta Arizona Arkansas Bermuda British Columbia California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming Yukon Territory Other
Zip or Postal Code:
Country:
*Phone:
Fax:
*E-mail:

2) Please complete the amount(s) owed in the corresponding boxes below:

Taxes Owed

Personal Income Tax $:
Business Income Tax $:
Payroll Tax $:
State Tax $:
*Total Taxes Owed = $: Must be at least $10,000

3) Please check all that apply:

IRS Collection Activity

No current collection activity (no mail or phone calls regarding my tax debt for the last 6 months):
I received a letter/or letters, but no CERTIFIED MAIL regarding my tax debt:
I received some CERTIFIED mail or a PHONE CALL regarding my tax debt:
I received a GARNISHMENT, WAGE LEVY, BANK LEVY or PROPERTY SEIZURE:

Any added tax history or financial information in regards to your tax problem is appreciated:

4) Please read the agreement statement below:

Terms of Use

Nationwide Tax Relief will not share the contents of this form. nor shall the contents of this form be sold or distributed to a third party. Any other use of these contents is a violation of privacy laws and the ethics of Nationwide Tax Relief.

   

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