﻿Department of the Treasury -Internal Revenue Service

Form 15104
(June 2017)
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 ----

Catalog Number 69798V
www.irs.gov
Form 15104 (6-2017)
