Client Data Form
     
     

PERSONAL INFORMATION

*Your Full Name:  

Spouse's Name:  

Address Line - 1:  

Address Line - 2:  

City:  

County:  

State:  

Zip Code:  

Home Phone:  

Work Phone:  

Best time to call you:  

*Email:  

Number in household:  

Are you employed?  

Do you own a business?  

Any prior bankruptcies?  

TAXES OWED:

Type of tax Tax period Amount owed
$		 Check liable
party

You Spouse

You Spouse

You Spouse

You Spouse

You Spouse

Any tax returns unfiled?
Give details including
years and estimate of
amount owed per year:

Approx. credit card debt:

HOUSING INFORMATION:

Monthly Payment or Rent:                    

Utilities:                    

Do you own your house?                    

 Yes No

If you answered YES...                    

Current Market Value:                    

Current Amount Owed:                    

Owner(s) of Record:                    

VEHICLE INFORMATION:

First Vehicle                    

Monthly Payment:                    

Current Market Value:                    

Current Amount Owed:                    

Owner(s) of Record:                    

Second Vehicle

Monthly Payment:                    

Current Market Value:                    

Current Amount Owed:                          

Owner(s) of Record:                    

OTHER ASSETS:

    

Owner of Record

Market Value

Cash on hand or in banks:

Stock & Securities:

IRA's and Retirement plans:                  

Life Insurance cash value:

Equity in other real estate:

Value of business owned:

Accounts/notes receivable:

Beneficiary of trust/estate?:

Other assets (describe):

MONTHLY INCOME:

  

Monthly (You)

Monthly (Spouse)

Gross Income:

Interest & Dividends:

Income from business:

Net rental income:

Social Security & Pension:                      

Alimony/child support:

Disability Income:

Other Income:

MONTHLY EXPENSES:

  

Monthly Amount
(You)

Monthly Amount
(Spouse)

Health Insurance:

Other health costs:

Federal and state taxes:

Court ordered payments:

Child/dependent care:

Life insurance premiums:                       

Child support paid:

Alimony paid:

Other secured debt:


Have you ever filed and offer in compromise?

 Yes No

When?

What taxes were included?

Was the offer accepted by the IRS?

 Yes No

Have you been on an installment agreement lately?

 Yes No

Is it still in force?

 Yes No

Is the IRS threatening to "default" the agreement?

 Yes No

Are there any special circumstances that we should take into account?

 Yes No

Health problems?

 Yes No

Other financial problems?

 Yes No
Other comments and/or questions you may have:
 

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9273 Old Keene Mill Road   :   Burke, Virginia 22015   :   Telephone 703-913-7500   :   Toll Free: 888-913-7501   :   Fax 703-866-2427
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BJ Haynes is a tax and IRS lawyer who assists clients with tax problems, IRS problems, tax liens, tax audits, tax returns, tax evasion, tax fraud, tax court, IRS audits, IRS levies, IRS criminal investigations. The law office of Burton J. Haynes, PC practices in all states including Virginia, Maryland, and Washington DC with both civil and criminal tax problems.

This may be considered AN ADVERTISEMENT or Advertising Material under the Rules of Professional Conduct governing lawyers in Virginia. This web site is designed for general information only. The information presented at this site should not be construed to be formal legal advice nor the formation of a lawyer/client relationship. As required by U.S. Treasury Regulations governing tax practice, you are hereby notified that any tax advice contained in this communication (including any attachments) was not written or intended to be used, and cannot be used, for the purpose of (i) avoiding tax-related penalties under the Internal Revenue Code or, (ii) promoting, marketing or recommending any matters to another party.

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