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Do you Qualify

If you wish to download a more detailed form, click and receive the PDF file "Qualifier". Print the form, fill it out and then fax it to me toll free at (888) 542-4255.

This PDF file requires the Adobe Acrobat Reader in order to print out. If you don't have the Adobe Acrobat Reader, click on the logo to the right and download it now for free.

Please answer these few questions, then click the SUBMIT button at the bottom. If you prefer, you can print this form and fax it to me. The process takes 5 to 10 minutes. All information is confidential and is never revealed to anyone for any reason. You are protected by attorney-client privilege.

Personal Section

Enter your First Name or a Handle

Enter your EMAIL Address

Confirm your EMAIL Address
(Invent a handle if you would rather remain anonymous) (Your email address is VERY IMPORTANT! If you do not enter your email address properly then you will not be able to receive our analysis).
 

Are you in any Bankruptcy Proceeding at this time?

Yes No
Are you paying your required estimated taxes (if any) for this year?
Yes No
If married, do you file Jointly or Separately, or are you Single?
Jointly Separately Single

Are you willing to modify your income and/or expenses if necessary to qualify for IRS tax relief?
Yes No

Are you willing to file all tax returns, current and future, on time, paying all amounts when due without extensions?
Yes No

Are you aware that the IRS has wide discretion to accept or reject your application for tax relief and doesn't have to disclose the reasons for rejecting?
Yes No

Check the years for which you have not filed a tax return
2005 2004 2003 2002 2001 2000 1999 1998 1997 1996

Congratulations on beginning to address this problem. What stopped you before now?

The IRS says I owe:
The IRS has sent me a "Notice of Intent to Levy"  Dated
The IRS has sent me a "Notice of Levy"?  Dated

Income Section

What is your marital status?

How many ADULTS are in your household?

How many CHILDREN are in your household?
How are you paid?
Yourself
 Spouse
What is your gross pay before any deductions per pay period?
(If self-employed and you do not have another job, enter 0)
Yourself
 Spouse
If self-employed, what is your annual net income after business expenses but before personal expenses?
(if not self-employed, enter 0)
Yourself
 Spouse
If self-employed, what are your total annual business expenses?
(if not self-employed, enter 0)
Yourself
Spouse
Amount of Alimony received per month
Amount of Child Support received per month
Total amount of Private Pension, Civil Retirement, Social Security or Disability payments received per month
Yourself
Spouse

Equity Section

To calculate equity, take the current value of the following items and subtract from that amount what you still owe. If you owe more than the current value, enter 0.
Equity in all the real estate you own
 		Equity in all vehicles you own
 		Cash on hand or in the bank (checking and savings)
Money in 401K accounts
 Money in IRAs
 Money in CDs stocks, or other investments
Do you own anything else of value (boats, jewelry, guns, fine art, antiques, etc.)?
Yes No

Expense Section
Monthly Average
Monthly mortgage or rent
 		 Property tax per month if not included in your mortgage? Homeowner's Insurance per month if not included in your mortgage?
Monthly charge for security or alarm system
 		Monthly Homeowner's or Condo Association dues
 		Monthly fee for trash pick-up
Monthly home phone bill
 		Monthly cell phone bill
 		Monthly electric bill
Monthly gas bill
 		Monthly water bill
 		Gas, Repair, Maintenance on all cars
Monthly payment on 1st car
 		Monthly payment on 2nd car
 		Total monthly car insurance
Health insurance deducted per paycheck
Yourself
 Spouse
Premiums for health insurance you pay directly.
 		Monthly costs for Rx, Dentists, Co-Pays and any other out-of-pocket health care expenses.
Life Insurance Premiums deducted per paycheck
Yourself
 Spouse
Other life insurance monthly premiums
 		Child care
Amount of Alimony or Spousal Support you pay each month
 		Amount of Child Support you pay each month
 		Amount you are paying monthly toward pay garnishments
Amount you are paying monthly toward old state or local taxes
 		Monthly student loan payments
 		Monthly payments on secured debts (debts where the collateral could be taken back if you defaulted)
Federal income tax withheld per paycheck
Yourself
 Spouse
State and local tax withheld per paycheck
Yourself
 Spouse
Total Medicare and FICA withheld per paycheck
Yourself
 Spouse
 We need to know:
Your Date of Birth Spouse Date of Birth
Your State of residence Your County of residence

Sometimes, you can qualify for an Offer in Compromise if you have a significant hardship. Do you have a hardship?

Yes No

Do you have any other expenses you think should be allowed?

Yes No

In case we need to clarify your answers, please give us the following information.
Phone number Who to ask for Best time to call

 
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