Form 15103 - Form 1040 Return Delinquency Page 2
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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
15103
Catalog Number 69797K
Form
(6-2017)
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