Form 15103 — Form 1040 Return Delinquency

Official source: IRS Forms, Instructions & Publications (https://www.irs.gov/pub/irs-pdf/f15103.pdf), retrieved 2026-10-03. U.S. Government work (17 U.S.C. § 105).

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(June 2017)

Department of the Treasury - Internal Revenue Service

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

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 Single

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 www.irs.gov Form 15103 (6-2017)

Page 2

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

Catalog Number 69797K www.irs.gov Form 15103 (6-2017)