Fillable Form 15103: (IRS)

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Form 15103: (IRS)

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The Form 15103: (IRS) form is 2 pages long and contains:

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  • 20 check-boxes
  • 31 other fields

Country of origin: US
File type: PDF

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The Internal Revenue Service (IRS) is a government agency responsible for collecting taxes and administering the federal statutory tax laws of the United States. The IRS provide tax assistance to taxpayers and pursue and resolve fraudulent tax filings.

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Catalog Number 69797K www.irs.gov
Form
15103 (6-2017)
Form 15103
(June 2017)
Department of the Treasury - Internal Revenue Service
Form 1040 Return Delinquency
Complete both sides of this form and send it to us in the enclosed envelope. Be sure our address shows through the window.
Contact information
Social Security Number Taxpayer name
If your address has changed, make the changes below
Address City State ZIP code
Primary telephone number Best time to call
a.m.
p.m.
Secondary telephone number Best time to call
a.m.
p.m.
Indicate whether any of the following circumstances apply to you
If you already filed a tax return
I already filed my tax return for
and I am enclosing a signed and dated copy of the return as verification.
Name(s) shown on return
Form(s) filed
Tax return year(s) Tax return date(s)
If the person addressed on this notice is deceased
Date of death
I already filed a Form 1041, Income Tax Return for Estates and Trusts, instead of a Form 1040.
Name(s) shown on return
Employer identification number (EIN) listed on Form 1041
Tax return year
If you don’t think you have to file a tax return for
Explain why you don't think you are required to file a tax return for . Note: The answers to these questions apply to the
tax
year only.
My filing status was
Head of household Single
Married filing jointly Qualified widow(er) with dependent child
Married filing separately
The following applied to me
I was 65 or older I am not a U.S. citizen or permanent resident
I was blind My work was performed in another country
My spouse was 65 or older I could be claimed as a dependent on someone else’s return
My spouse is blind
My total income
Reason for not filing
Page 2
Catalog Number 69797K www.irs.gov
Form
15103 (6-2017)
Indicate whether any of the following circumstances apply to you (continued)
taxes or made estimated tax payments forIf you have a refund from a prior year that you applied to your
taxes
I want to apply the credit to another tax return.
Note: You must file a return for
to apply the prior year credit.
Tax form number Tax period ending Social Security Number
I want to receive the credit as a refund check.
Note: You must file a tax return to be eligible for a refund even though you may not be required to file.
Sign and mail to us
Under penalties of perjury, to the best of my knowledge and belief, I declare that all information I provided on this form, as well as all of
the information in my attached income tax return and accompanying schedules and statements, is true, correct and complete.
Signature Date
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Form 15103: (IRS)

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Completed 21 January 2022

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