Form 15103 - Form 1040 Return Delinquency

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Department of the Treasury - Internal Revenue Service
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
ZIP code
Primary telephone number
Best time to call
Secondary telephone number
Best time to call
Indicate whether any of the following circumstances apply to you
If you already filed a tax return
and I am enclosing a signed and dated copy of the return as verification.
I already filed my tax return for
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
year only.
My filing status was
Head of household
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
Catalog Number 69797K


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