
Form 15103 
Form 1040 Return Delinquency
(June 2017)
Cat. No. 69797K

Provided by the:
Internal Revenue Service
Alternative Media Center

In 1 File
Print pages 1-2

Contents

Section:  Page
Form 15103:  1
Contact information:  1
Indicate whether any of the following circumstances apply to you:  1
Sign and mail to us:  2

This electronic edition contains the entire text of the print edition.

<page 1>

Form 15103
Form 1040 Return Delinquency
(June 2017)

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
   -- Married filing jointly
   -- Married filing separately
   -- Single
   -- Qualified widow(er) with dependent child
   The following applied to me
   -- I was 65 or older
   -- I was blind
   -- My spouse was 65 or older
   -- My spouse is blind
   -- I am not a U.S. citizen or permanent resident
   -- My work was performed in another country
   -- I could be claimed as a dependent on someone else's return
   My total income: ----
   Reason for not filing: ----

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Indicate whether any of the following circumstances apply to you (continued)
If you have a refund from a prior year that you applied to your ---- taxes or made estimated tax payments for ---- 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: ----

End of Form 15103
