MT CLEMENS

Client Interview Form

Full Name *

Tax Preparer *

1. List all sources of income (including SSI benefits, wages, self-employment, Unemployment Income or others) and how are you supporting yourself and your dependent(s)? *

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? *

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

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

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

9a. Do you own or rent? *

OWN

RENT

9b. Rent amount or taxed paid. *

9c. Landlord Name and Address or Mortgage Company *

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.

Signature *

Clear