<p> Case No. ______INTAKE SHEET</p><p>Student Attorney ______Date Initial Contact: </p><p>Date originally opened/assigned ______Referral: </p><p>TAXPAYER(S) </p><p>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</p><p>Gender Age Handicapped Disabled First Language </p><p>Ethnicity (White, Black, Hispanic, Native American, Asian…)</p><p>STATUS ON RECEIPT</p><p>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</p><p>(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</p><p>Office use only: CL___ CLA___ NS___ NSA____ T’ Dr___ Copied Intake___ Linked to Amicus___Amicus___PACER___Accurint___</p><p>Supp. Issues_____ Scan Quest______Case No. ______Step 1: Complete Basic Intake & Route to Conflicts Referral: Date: </p><p>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)</p><p>ROUTE TO CONFLICTS: Date: By: </p><p>Step 2: Complete Conflicts Check</p><p>Conflicts Check:</p><p>Date Completed: ______By: ______</p><p>Names Searched No Match Match</p><p>IF MATCH FOUND, CONTACT MARIANA CHRISTINA PANNELL</p><p>(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</p><p>Office use only: CL___ CLA___ NS___ NSA____ T’ Dr___ Copied Intake___ Linked to Amicus___Amicus___PACER___Accurint___</p><p>Supp. Issues_____ Scan Quest______Case No. ______</p><p>Name: </p><p>Step 3: Make Representation Decision and Route to Conflicts</p><p>Representation Determination:</p><p>Clinic accepted representation: Yes No (circle one).</p><p>If no: Date non-engagement (declination) letter sent: ______</p><p>If yes: Date signed engagement letter received from client: ______</p><p>The parties listed on the initial contact check are correct: Yes No (circle one) If no, please note any changes here:</p><p>Representation decision entered into Clio by: ______Date: ______</p><p>Step 4: Close File and Route to Conflicts</p><p>Accepted matter concludes</p><p>Representation concluded on: ______Disengagement letter sent: Yes___ No___</p><p>Entered into Conflicts database by: ______Date: ______</p><p>(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</p><p>Office use only: CL___ CLA___ NS___ NSA____ T’ Dr___ Copied Intake___ Linked to Amicus___Amicus___PACER___Accurint___</p><p>Supp. Issues_____ Scan Quest______</p>