Tax Lien Questionnaire Name (required): City/State: Telephone: Email (required): Date of Birth: Date you received our letter: Lien Amount: Who filed the lien? ---StateIRS Filing Status ---SingleMarried JointMarried SeparateHead of Household What do you do for a living? What does your spouse do for a living? What was your total income last year from all sources? And your spouse's total income? During the tax years involved, did you get a form W-2, 1099, or both? ---W-21099Both Were taxes withheld? ---YesNo Please estimate the current value of your home How much is owed on your home? What is the value of any stocks, bonds, IRAS, etc? During the problem years, did you experience any unusual transactions such as stock sales, IRA distribution, home sales, cancellation of debt, etc? ---YesNo For what years have you not filed tax returns? How many properties do you own other than your residence? What is the total value of your other properties? How much do you owe total on all properties? Does anyone in your family have a serious medical condition that requires you to pay large medical bills out of pocket because it is not covered by insurance? ---YesNo Have you been in contact with the IRS regarding your tax lien? ---YesNo If yes, quickly outline that conversation Did you set up a payment plan or has an offer rejected? ---YesNo Can you think of anything else that would affect your financial situation that we have not already discussed? Please leave this field empty.