Low Income Taxpayer Clinic Client Application Form
Sign in to Google to save your progress. Learn more
Email *
First Name: *
Last Name: *
Date of Birth: *
MM
/
DD
/
YYYY
Address (City, State Zip Code): *
No P.O. Boxes
Preferred Telephone Number: *
Alternate Telephone Number:
Best time to call: *
Tax years in question (select all that apply): *
Required
Amount due to the IRS: *
Briefly describe your tax issue: *
Have you received a letter from the IRS?  *
If yes, please list the notice number and date received
How many people are in your household (related by blood/marriage/adoption)? *
Income
Please tell us how much income you receive from the following sources
Wages
Amount of gross (pretax) W-2 income/month
 *
Unemployment
Amount of gross (pretax) unemployment income/month
 *
Social Security/SSI
Amount of gross (pretax) Social Security income/month
 *
Self-Employment
Amount of gross (pretax) income/month
 *
Rental Income
Amount of gross (pretax) income/month
 *
Gambling Winnings
Amount of (pretax) income/month
 *
Interest and/or Dividends
Amount of gross (pretax) income/month
 *
Child Support and/or Alimony
Amount of gross (pretax) income/month
 *
Pension 
Amount of gross (pretax) income/month
 *
Do you own any real estate? *
If yes, what type and where?
Do you own a small business? *
Does anyone else living in your home receive income? *
If yes, how much income do they receive and from where? (list person, source of income and gross (pretax) amount)
How did you hear about us? *
I hereby affirm that the financial information I have provided to Accounting Aid Society's Low Income Taxpayer Clinic is accurate. *
Please type your complete name below:
Date:  *
MM
/
DD
/
YYYY
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Accounting Aid Society.

Does this form look suspicious? Report

Google Forms