Date of Encounter
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Today M-D-Y
VIDEO
Thank you for your interest for the UNM Office for Community Health Family Financial Well Being for financial and tax assistance.
Self - Referral
ASL - Self Referral
Organizational Encounter
As a future client please fill out the requested information for best assistance.
Organization
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Office for Community Health Other
Organization Employee filling this form
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Employee email:
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What type of encounter will you be recording?
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Referral of potential client
Tax/Financial Assistance Appointment
Post Tax Filing Appointment
Client Information Client First name: Prefered Languge(s):
What social services do they currently have?
Client Last name: Include at least one contact method: Phone number: Email: Other contact method:
Other contact contact information/username:
To help us better match you with tax serivices please provide your New Mexico County of residance:
Client's First Name:
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Client's Last Name:
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Other contact method username/ID
County Residence in Referral Form:
Bernalillo County Guadalupe County Luna County Torrance County Valencia County
Client Preferred Language(s):
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Other Client Preferred Language(s):
Does the client need a translator to receive services?
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Yes
No
What social services does the client currently have?
What other social services does the client currently have?
Income sources for the client (or client's spouse) in the time period needing financial assistance.
Types of incomes, check all that apply:
Describe income sourses, and any others sourses of income not included in the check list.
What year(s) does the client need tax assistance with?
Does the client qualify for EITC?
Yes
No
Unsure
What financial assistance will the client need?
Other Financial Assistance need:
Can you describe the client's situation:
Types of income listed on Reference:
How many jobs with W-2 have you had in the relevant time period?
How many jobs with 1099 forms have you had in the relevant time period?
Number of jobs with 1099 forms:
Including this appointment, how many appointments has your organization had with the client to help with their financial well being?
How long did the appointment last in minutes?
Were you able to file the clients taxes in this appointment?
Yes
No
What years of tax performs did you help the client with?
2019 Tax Return Information Refund type Return Amount Notes Federal Total EITC (Federal) Federal Child tax credit (Federal) State Total Return
Working Families Tax Credit (State) State Child Tax Credit (State) Total
2020 Tax Return Information Refund type Return Amount Notes Federal Total EITC (Federal) Federal Child tax credit (Federal) State Total Return
Working Families Tax Credit (State) State Child Tax Credit (State) Total
2021 Tax Return Information Refund type Return Amount Notes Federal Total EITC (Federal) Federal Child tax credit (Federal) State Total Return
Working Families Tax Credit (State) State Child Tax Credit (State) Total
2022 Tax Return Information Refund type Return Amount Notes Federal Total EITC (Federal) Federal Child tax credit (Federal) State Total Return
Working Families Tax Credit (State) State Child Tax Credit (State) Total
2023 Tax Return Information Refund type Return Amount Notes Federal Total EITC (Federal) Federal Child tax credit (Federal) State Total Return
Working Families Tax Credit (State) State Child Tax Credit (State) Total
2024 Tax Return Information Refund type Return Amount Notes Federal Total EITC (Federal) Federal Child tax credit (Federal) State Total Return
Working Families Tax Credit (State) State Child Tax Credit (State) Total
2025 Tax Return Information Refund type Return Amount Notes Federal Total EITC (Federal) Federal Child tax credit (Federal) State Total Return
Working Families Tax Credit (State) State Child Tax Credit (State) Total
2026 Tax Return Information Refund type Return Amount Notes Federal Total EITC (Federal) Federal Child tax credit (Federal) State Total Return
Working Families Tax Credit (State) State Child Tax Credit (State) Total
Federal Child Tax Credit Amount
Federal Child Tax Credit Amount
Federal Child Tax Credit Amount
Federal Child Tax Credit Amount
Federal Child Tax Credit Amount
Federal Child Tax Credit Amount
Federal Child Tax Credit Amount
Federal Child Tax Credit Amount
State Working Family Tax Credit
State Working Family Tax Credit
State Working Family Tax Credit
State Working Family Tax Credit
State Working Family Tax Credit
State Working Family Tax Credit
State Working Family Tax Credit
State Working Family Tax Credit
Total Year Return
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Find out the total EITC contribution
View equation Find out the total tax returns
View equation The Earned Income Tax Credit (EITC) refund amounts totaled to 0 or were left blank.
No Social Security Number
Residency Status
Income too high
No earned income
Other
Other reason best describes why they didn't qualify for EITC?
Please remember to ask client demographics and record below. Including this appointment, how many appointments has your organization had with the client to help with their financial well being?
Reason for post filing appointment:
Other reason for post filing appointment:
Can you describe why the client needs help after filing for taxes?
Will they need to be referred to another agency for help resolving this issue?
Yes
No
What agency the client being referred for help for their problem?
What is the specific issue that requires the client to be referred to another agency?
What financial services or education was provided to the client in this meeting?
What services was the client referred to?
What other financial help did you provide in the meeting?
What Bank on help was provided?
What other Bank on help was provided?
Age
Filling status:
Number of claimed dependants:
Zip Code:
Household income: Highest level of education: What is the client's current employment status?
Which of the following best describes where the client lives?
Does Client have a smart phone?
Select all of client's idenified race/ethnicities:
Client Peferered Languages:
Languages used in client's home:
Gender Does client identify with the LGBTQ+ community?
Does the client have one or more disabilities?
Primary County of Residence:
Not New Mexico Resident Bernalillo County Catron County Chaves County Cibola County Colfax County Curry County De Baca County Dona Ana County Eddy County Grant County Guadalupe County Harding County Hidalgo County Lea County Lincoln County Los Alamos County Luna County McKinley County Mora County Otero County Quay County Rio Arriba County Roosevelt County Sandoval County San Juan County San Miguel County Santa Fe County Sierra County Socorro County Taos County Torrance County Union County Valencia County
Non New Mexican primary residence:
Client Preferred Language(s):
Client Preferred Language(s) Demographic Section:
What languages is used in the client's home?
Client home languages other:
Select all of the client's race/ethnicity
Male
Female
Non Binary
Transgender
Other / Self Describe
Prefer not to answer
Does the client identify as part of the LGBTQ+ community
Yes
No
Prefer not to answer
Does the client have one or more disabilities?
Yes
No
Prefer not to answer
Please indicate what types of disability/impairment:
Specifics on disabilities if client wants to disclose:
Single
Married filing jointly
Married filing separately
Head of household
Qualifying widow(er) with dependent child
Other
Client number of dependents:
0- 15,000
15,000 - 24,999
25,000 - 34,999
35,000 - 49,999
50,000 - 74,999
75,000 -99,999
100,000 and above
Client highest education:
Some High School
High School Degree / GED / HiSET
Some College
Associate Degree
Trade School / Vocational degree
Bachelor Degree
Advanced Degree
Other
What is the client's current employment status?
Unemployed
Employed full time
Employed part time (one job)
Employed part time (multiple jobs)
Self-employed
Declined to answer
Which of the following best describes where the client lives?
In a home that the Client own
In a home that someone else in the Client's household owns
In a home or apartment that the Client rent
In a home or apartment that someone else in the Client's household rents
Homeless (living only on the streets)
In transition
Shelter
Hotel
Friend's house/couch surfing
Other
Declined to answer
Does the client have a smart phone?
Yes
No
Other