LITC Potential Client Intake Form

Please note that you do not automatically become a client by submitting this form. After receiving your completed form, the LITC will contact you to set up an initial consultation meeting to determine if we can accept you as a client. Please leave blank if it does not apply to you or you do not know. Please note that information sent by potential or current clients is confidential to the client, and as such will not be shared with any third parties outside of WashULaw LITC or others unless they have signed an explicit confidentiality agreement.

First Name*

Last Name*

Date of Birth*

Marital Status*

Filing Status*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Preferred Telephone*

Alternative telephone

Email*

Best Hours to Contact You*

Gender

Disabled / Handicapped*

First Language*

Tax Years in Question*

Amount Due in Question*

Briefly Describe your Tax Issue*

How many people in your household and what is their relationship to you?*

Does anyone in your household, other than you, receive income? If so, how much (Please specify pay period.)?*

Types of Income Please tell us how much income you receive from the following sources. Please specify how often you receive this income (weekly, biweekly, monthly, etc.) Leave blank if it does not apply to you:

How frequently are you paid?

Wages, how much per pay period before taxes are taken out?*

Must be a dollar amount.

Unemployment*

Social Security/Pension/Disability*

Self-Employment*

Rental Income*

Gambling Winnings*

Dividends*

Disability*

Child Support*

Alimony Received*

Do you own a small business?*

Do you own real estate? If so, what type and where?*

Do you have a mortgage?*

Type of Form*

Audit Notice
30 Day Letter
90 Day Letter
Notice of Lien
Notice of a Intent to Levy

Date Letter Received*

Are you aware of any due dates?*

(1) Are you currently in bankruptcy or planning to file?*

Are you currently represented by an attorney?*

Are you able to upload documents?*

Yes
No

Are you able to download documents?*

Yes
No

How did you hear about us?*