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First Name *
Last Name *
Phone Number *
Email *
Address
City, State, Zip *
1. Amount of Federal Tax Owed
2. Amount of State Tax Owed
3. Amount of Unsecured Debt (Credit Card, Medical, etc.)
4. Do you have any tax liens? YesNo
5. Have you recently filed a bankruptcy? YesNo
6. Is any of that debt past due? YesNo
7. What are the circumstances that lead to the current situation/hardship?

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