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Section 1 of 23
LIA- Client Information Form


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Section 2 of 23
Primary Household Member
First Name
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Last Name
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Date of Birth
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02131975
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Gender
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Female
Male
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add "Other"
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Phone Number
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xxx-xxx-xxxx
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Phone Number 2
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xxx-xxx-xxxx
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Social Security Number
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Immigration Status
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Citizen
Green Card
I-797
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Marital Status
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Married
Single
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Section 3 of 23
Spouse Details
First Name
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Last Name
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Gender
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Male
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Date of Birth
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11061976
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Social Security Number
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Immigration Status
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Citizen
Green Card
I-797
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Section 4 of 23
Dependents
How many dependents you have?
Question Type
Include any members that will file taxes with you
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1.
0
2.
Option 2
3.
2
4.
3
5.
4
6.
5
7.
6
8.
7
9.
8
10.
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Section 5 of 23
Dependent Details
Relationship to the primary household member
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First Name
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Last Name
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