Catalog Number 69798V
15104 (6-2017)
Form 15104
(June 2017)
Department of the Treasury - Internal Revenue Service
Status of the Taxpayer Levy
Employer's name Employer Identification Number (EIN)
Taxpayer's name Social Security Number (SSN)
If you already mailed the amount required or don't owe any money to the taxpayer, complete the information below. Return this form to
us in the enclosed envelope, or if you prefer to give the information by phone, call us at the number listed on the attached letter.
1. We sent the amount to you
Date mailed Amount mailed
Address mailed to
2. We don't owe this taxpayer any money (explain)
3. We no longer employ this taxpayer (list taxpayer's last known address, phone number and current employer, if known, or any information to
help us locate this taxpayer)
Last known address
Telephone number Current employer
Additional information
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