Tax Debt Case Intake Form
Law Office of Peter J. Clarke, PLLC

Please complete this intake before your meeting with Attorney Clarke so he can spend more time evaluating your financial situation and then recommend a tax resolution option and costs that are right for your situation.

Completing this worksheet does not create an attorney–client relationship and is not legal advice. Please do not send this document or any other documents by email.

Step 1 · Taxpayer Info and Tax Debt

The IRS considers household details when reviewing collection options. Answer based on your current situation.

Household & Marital Questions

What state do you currently live in?
What county is your primary residence in?
What is your marital status?
If married, will you be submitting any forms jointly with your spouse?
Do you live in a community property state? Updates automatically based on your state, but you can change it.
How many people in your household are age 65 or older?
How many dependents did you claim on your most recent tax return?
How many vehicles in the household?
How many of those vehicles are over 9 years old or have 125,000+ miles?

Tax Years and Liabilities

Enter each tax year separately. An approximate filing date is fine — exact dates can be confirmed from IRS account transcripts at a later time.

Tax year Liability ($) Approximate date filed
Total federal liability $0
Step 2 · Assets

Please list assets based on current estimated values. Attorney Clarke will apply the IRS quick-sale discounts and exemptions.

Cash & Accounts

Cash or money in bank or online accounts
Balance
 
—

Investments & Digital Assets

Investment accounts Examples: Stocks, bonds, other
Balance
Loan amount
Digital assets
Balance
 
—

Retirement Accounts

Retirement accounts
Balance
Loan amount

Life Insurance

Cash surrender value of life insurance
Balance
Loan amount

Real Estate

Current value of your real property
Value
Loan amount

Vehicles

Market value of your vehicle
Value
Loan amount
Market value of your spouse's vehicle
Value
Loan amount

Other Assets

Other assets Examples: Boats, motorcycle, recreational vehicles, etc.
Value
Loan amount

Other Valuable Assets

Other valuable assets Examples: Jewelry, collections, artwork, business interests
Value
Loan amount

Business Assets

Business bank & digital asset balances
Balance
 
—
Other business assets
Value
Loan amount
Totals (as entered)
Balances & Values
$0
Loans
$0
Step 3 · Income

Enter average monthly amounts based on your current situation.

Your Income

Average gross monthly wage income from an employer
$
Average monthly Social Security benefits
$
Average monthly pension or retirement income
$
Unemployment, gig work, digital platform income, subsidies, gambling, etc.
$

Spouse's Income

Spouse's average gross monthly wage income
$
Spouse's average monthly Social Security benefits
$
Spouse's average monthly pension or retirement income
$
Spouse's unemployment, gig work, digital platform income, etc.
$

Other Household Income

Income contributed by anyone else in the household Shown for context — not counted in the payment capacity totals.
$

Additional Income Sources

Interest, dividends, or royalties (household)
$
Distributions (partnerships, sub-S corporations, etc.)
$
Net rental income (household)
$
Net business income (household)
$
Child support received
$
Alimony received
$
Total entered monthly income
$0
Step 4 · Expenses

Attorney Clarke will apply IRS standards to your expenses to either increase certain expenses or to cap others according to IRS rules & regulations.

Household Expenses

Food, Clothing & Miscellaneous
$
Housing & Utilities Examples: Rent or mortgage, utilities, insurance, taxes, fees
$
Your Vehicle Loan or Lease Payment
$
Spouse's Vehicle Loan or Lease Payment
$
Your monthly Vehicle operating cost Examples: Fuel, insurance, maintenance, registration
$
Spouse's monthly Vehicle operating cost
$
Public transportation cost
$
Health Insurance Premiums
$
Out-of-Pocket Medical Expenses
$
Child or Dependent Care
$
Court-Ordered Payments Examples: Child support, alimony
$
Life Insurance Premiums
$
Current Monthly Taxes
$
Other Secured Debts or Required Expenses
$
Delinquent state and/or local tax payments
$
Total monthly expenses
$0
Step 5 · Forward Intake to Attorney Clarke

Your intake is ready — here’s how to get it to Attorney Peter J. Clarke

Your answers stay in your browser. Nothing is sent automatically. Choose whichever option you prefer — either way, you’ll get a free case evaluation.

Option A Save the PDF and bring it in

Save or print your completed intake, then bring the PDF to your consultation (or keep it for your records). Your financial details never leave your device. Please do not email the PDF to our office — email is not secure. If you’d like to send it ahead of your consultation, use only the secure intake form in Option B below.

Option B Upload it through our secure intake form

Prefer to send it ahead of time? Save the PDF using Option A, then open our secure online intake form, answer a few short questions, and attach your saved PDF at the end. It goes straight into our encrypted client system and we’ll follow up to schedule your free case evaluation.

🔒 Open the secure intake form

⚠️ Please do not send documents by email. Do not send the Tax Debt Case Intake Form PDF or any other documents to Attorney Clarke via email. Email is not a secure way to transmit financial information. This evaluation should be sent only through the secure intake form (Option B) or brought to your consultation in person (Option A).

🔒 Your privacy. Your answers stay in your browser on your own device and are never transmitted to our office unless you choose to send them. For your protection, complete this worksheet on a private, personal device rather than a shared or public computer, and store your saved PDF somewhere secure.

Completing this worksheet does not create an attorney–client relationship with the Law Office of Peter J. Clarke, PLLC. An attorney–client relationship is formed only by a signed engagement agreement. This worksheet is an information-gathering tool and is not legal advice.

Questions? Call our office at 603-233-4843 or email peter@pjclarkelaw.com — but please do not attach documents to emails.