Client Interview Form

Full Name *

1. List all sources of income ( including SSI/SSD benefits, wages, self-employment income, unemployment income or other) and how are you supporting yourself and your dependents if applicable? *

2. Do you receive state assistance? Yes No If yes, write down the type of assistance and the amount you receive each month. Example: Cash assistant, Food assistant, housing assistant? How much do you pay? *

3a. Indicate the total number of people living in your household *

3b. What is your total annual household income? *

4. Have your EIC (Earned Income Credit) ever been reduced or disallowed? Yes No. If Yes, when\what was the reason? *

5. Did you or your dependent attend any educational institution that may qualify for the American Opportunity Credit or the Lifetime Learning Credit? *

Yes

6. Did you pay for student loans and did you receive form 1098 E (student loan interest paid)? *

Yes

7. Do you have any garnishments such as IRS debt, child support, student loans, medical bills ETC? *

Yes

8. Did you receive a letter from unemployment stating that you owe or if your unemployment portal states that you owe for overpayment? *

Yes

9a. Do you own or rent? *

9b. Rent amount or taxes paid.

Personal Landlord Information (Address where you mail payments) *

Full Name or Company
Address Line 1
Address Line 2
City
State
Zip Code
Rent Amount
Months Rented

I agree to terms & conditions provided by the company. I confirm everything stated in the form is the truth to the best of my knowledge.