Has Any Relative Used Our Services Before? Name

Case No. ______INTAKE SHEET

Student Attorney ______Date Initial Contact:

Date originally opened/assigned ______Referral:

TAXPAYER(S)

Has any relative used our services before? Name: Are you currently in Bankruptcy? Have you used our services before? Family Size Marital Status Total Income current yr. $ Address County e-Mail Address: Home Phone Cell Work Best hours Is Taxpayer current on all taxes? Y N If not, what years have not been filed? STATISTICAL INFORMATION

Gender Age Handicapped Disabled First Language

Ethnicity (White, Black, Hispanic, Native American, Asian…)

STATUS ON RECEIPT

10- day letter date: Notice of Lien/Levy/Garnish dated: 30-day letter date: Expiration Date 90-day letter date: Expiration Date Tax Court Date: Docket No. Tax Year(s) Tax owed: $ Tax preparer for years in question: NARRATIVE

(Size of family)/Maximum income (2017) (1)/$30,150; (2)/$40,600; (3)/$51,050; (4)/$61,500; (5)/$71,950; (6)/$82,400; (7)/$92,850; (8)/$103,300; Add $10,450 ea.add’l

Office use only: CL___ CLA___ NS___ NSA____ T’ Dr___ Copied Intake___ Linked to Amicus___Amicus___PACER___Accurint___

Supp. Issues_____ Scan Quest______Case No. ______Step 1: Complete Basic Intake & Route to Conflicts Referral: Date:

Clinic: Investor Advocacy HeLP Tax Potential Client Name: Address: Phone Number: Home Cell Work E-mail Address (personal only): Other Potential Clients: Potentially Adverse Parties: Brief Description of Matter: (not needed for Tax Clinic)

ROUTE TO CONFLICTS: Date: By:

Step 2: Complete Conflicts Check

Conflicts Check:

Date Completed: ______By: ______

Names Searched No Match Match

IF MATCH FOUND, CONTACT MARIANA CHRISTINA PANNELL

Supp. Issues_____ Scan Quest______Case No. ______

Step 3: Make Representation Decision and Route to Conflicts

Representation Determination:

Clinic accepted representation: Yes No (circle one).

If no: Date non-engagement (declination) letter sent: ______

If yes: Date signed engagement letter received from client: ______

The parties listed on the initial contact check are correct: Yes No (circle one) If no, please note any changes here:

Representation decision entered into Clio by: ______Date: ______

Step 4: Close File and Route to Conflicts

Accepted matter concludes

Representation concluded on: ______Disengagement letter sent: Yes___ No___

Entered into Conflicts database by: ______Date: ______

Supp. Issues_____ Scan Quest______