In order to pre-qualify you for assistance, some basic information about your financial situation is required.

Please fill out the form below and feel free to advise us of additional relevant information about your case. This might include long periods of unemployment, underemployment, medical problems with any member of your family and so on. We will contact you promptly after receiving your pre-qualifier sheet. 

Also please tell me in your own words what your situation is and what you would like to see happen.  This is your story. Be frank, honest and objective. Anything you offer will help in evaluating your situation. Be assured, everything entered on this form is privileged communications and will NEVER be used for any other purpose.

Name: *
Address:
City, State, Zip *
Email: *
Daytime Phone: *
Evening Phone:
Best Time To Call:
The IRS says I owe: *
Number of years where I have not filed tax returns *
Detailed Description:





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