Section 1 of 23
LIA- Client Information Form
Email
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Section 2 of 23
Primary Household Member
First Name
First Name
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Time
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Last Name
Last Name
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Time
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Date of Birth
Date of Birth
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Date
Time
02131975
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Gender
Gender
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Date
Time
Female
Male
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add "Other"
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Phone Number
Phone Number
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Date
Time
xxx-xxx-xxxx
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Phone Number 2
Phone Number 2
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xxx-xxx-xxxx
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Social Security Number
Social Security Number
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Immigration Status
Immigration Status
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Date
Time
Citizen
Green Card
I-797
Other…
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Marital Status
Marital Status
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Date
Time
Married
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Single
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Section 3 of 23
Spouse Details
First Name
First Name
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Time
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Last Name
Last Name
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Paragraph
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Multiple choice grid
Checkbox grid
Date
Time
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Gender
Gender
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Paragraph
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Multiple choice grid
Checkbox grid
Date
Time
Female
Male
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add "Other"
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Date of Birth
Date of Birth
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Date
Time
11061976
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Social Security Number
Social Security Number
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Short answer
Paragraph
Multiple choice
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Dropdown
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Multiple choice grid
Checkbox grid
Date
Time
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Immigration Status
Immigration Status
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Citizen
Green Card
I-797
Other…
Add option
…
Answer key
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Section 4 of 23
Dependents
How many dependents you have?
How many dependents you have?
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Date
Time
Include any members that will file taxes with you
1.
0
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2.
Option 2
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3.
2
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4.
3
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5.
4
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6.
5
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7.
6
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8.
7
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9.
8
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10.
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Section 5 of 23
Dependent Details
Relationship to the primary household member
Relationship to the primary household member
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Time
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First Name
First Name
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
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Last Name
Last Name
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time