Tax Litigation Associates

Instructions:

You will find forms enclosed that we need filled out to the best of your ability. You will also be required to provide us
with certain documents. Returning your package back to us as quickly as possible will allow us to get to work on your file
swiftly so that we may resolve your tax issues.

Please fill out these forms as legibly and completely as possible. If you do not have the described documents requested
or do not understand the forms enclosed, please send what documents you do have and fill out the questions that
you understand and if there is anything missing that is critical, we will call you.

We will also require the following:

• copy of your Wage Levy notice (if applicable)
• Income:
o copy of last three most recent paystubs with year-to-date information, if W2 employee
o copy of a three month Profit and Loss statement, if self-employed
• Assets:
o copy of last three month’s bank statements for all accounts
o copy of most recent 401k, IRA, stocks or retirement account statements for each account
• Housing:
o copy of recent mortgage statement (or lease agreement if renting) and proof of payment.
o copy of proof of utility expenses for three months for electric, oil/gas, water/trash expenses and
phone/cell phone expenses
• Vehicles:
o copy of proof of car payment for last three months such as loan statement or cancelled checks
• Other types of expenses:
o copies or any court-ordered payments, such as a separation agreement for child and alimony payments
or court documents
o copy of proof of court-ordered payments such as child support, alimony, court costs, etc.
o copy of proof of child care payments for the last three months such as cancelled checks

“Pursuant to Internal Revenue Service Circular No. 230, please be advised that this communication (including any
attachments) is not intended or written to be used, and cannot be used by the taxpayer, for the purpose of avoiding
penalties that may be imposed on the taxpayer under the Internal Revenue Code.”
Tax Litigations Associates Fill out your current information for 2019 Page 1 of 3

TAXPAYER SPOUSE
First Name, MI First Name, MI
Last Name Last Name
Address Address
City, State Zip City, State Zip
County County
Social Security No: Social Security No:
Citizenship (if not U.S.) Citizenship (if not U.S.)
Date of Birth Date of Birth
Date of Death Date of Death
Phone Number Phone Number
Cell Number Cell Number
EMPLOYER
Job Title Job Title
Name of Employer Name of Employer
Address Address
City, State Zip City, State Zip
Phone Phone
Payroll Contact Name Payroll Contact Name
Payroll Contact Phone Payroll Contact Phone
Payroll Contact Fax Payroll Contact Fax
How long at Employer? How long at Employer?
Current Year to Date Current Year to Date
Total Income Total Income
Total Income from Last Total Income from Last
Year’s 1040 Tax Year’s 1040 Tax
Return Return
Paid weekly, monthly, Paid weekly, monthly,
semi-monthly or semi-monthly or
bi-weekly? bi-weekly?

CURRENT DEPENDENTS IN YOUR HOUSEHOLD (list more on additional page if necessary)

Name SS# DOB relationship Full time student?

Please sign below to certify under penalty of perjury that you are providing true and correct information.

Taxpayer _ Spouse
Date
Tax Litigations Associates Fill out your current information for 2019 Page 2 of 3

ACCOUNTS / LINES OF CREDIT (Includes Banks, Savings and Loans, Credit Unions, CDs, IRAs, 401(k)s, Pensions,
Mutual Funds, Brokerage Accounts)
Name and Address of Institution Type of Account Current Balance/Value

REAL ESTATE (home, vacation property, timeshares and other real estate)
Monthly Year Purchase Current Balance
Primary Address Payment Taxes Insurance Purchased Price Value Owed

Year Refinance
Refinanced Amount

Monthly Year Purchase Current Balance

Other Address Payment Taxes Insurance Purchased Price Value Owed

Year Refinance
Refinanced Amount

Monthly Year Purchase Current Balance

Other Address Payment Taxes Insurance Purchased Price Value Owed

Year Refinance
Refinanced Amount

OTHER ASSETS (cars, boats, recreational vehicles, whole life policies, etc.)
Monthly Year Final Payment Balance
Description Payment Purchased (mo / yr) Current Value Owed

Please sign below to certify under penalty of perjury that you are providing true and correct information.

Taxpayer Spouse
Date
Tax Litigations Associates Fill out your current information for 2019 Page 3 of 3

CREDIT CARDS (Visa, MasterCard, American Express, Department Stores, etc.)

Type Credit Limit Balance Owed Minimum Monthly Payment

NON-WAGE HOUSEHOLD INCOME (List monthly amounts. For Self-Employment and Rental Income, list the monthly
amount received after expenses)
Alimony Income: Net Rental Income: Interest Income:
Child Support Income: Unemployment Income: Social Security Income:
Net Self Employed Income: Pension Income: Other:

MONTHLY NECESSARY LIVING EXPENSES (List monthly amounts.)

1. Food / Personal Care 4. Medical
Food: Health Insurance:
Housekeeping Supplies: Out of Pocket Health Care:
Clothing & Clothing Services: 5. Other
Personal Care Products & Services: Child / Dependent Care:
Misc.: Estimated Tax Payments:

2. Transportation Term Life Insurance:

Gas/Insurance/Licenses/Parking/ Retirement (Employer Required):
Maintenance etc.: Retirement (Voluntary):
Public Transportation: Court Ordered Payments:

3. Housing & Utilities

Rent:
Electric, Oil/Gas, W ater/Trash:
Internet/Cable/Telephone and/or Cell Phone:

Please sign below to certify under penalty of perjury that you are providing true and correct information.

Taxpayer Spouse
Date