Cedamichigan.org



STATE INTAKE FORM (PLEASE PRINT)

Your Name _________________________________________________________________

Home Owners and Mobile Home Owners

|Did you bring your 2020 |2020 Taxable Value $ | |Mobile Home Owners |

|property tax statements | | | |

|with you? | | | |

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|Yes No | | | |

| | | |What is the amount of your lot rent per month? $ |

| |2020 Summer Taxes $ | | |

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| |2020 Winter Taxes $ | | |

| | | |Who do you pay your lot rent to? |

| CONTINUE TO BACK PAGE |

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Renters Only

|Where did you live during 2020? |What was the Landlord’s Name? |How many months did you live here during 2020? | |

|(Street Address, City, State, Zip Code) |(include City and State) | | |

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|First Address | | | |

| | |What was the amount of rent you paid per month? |$ |

| | |Is your name on the lease agreement? |Yes |No |

| | |Did anyone else live with you other than your spouse and/or|Yes |No |

| | |children? | | |

| | |Did anyone help you with paying the rent? |Yes |No |

| | |Is your rent subsidized (Section 8, etc)? |Yes |No |

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|Where did you live during 2020? |What was the Landlord’s Name? |How many months did you live here during 2020? | |

|(Street Address, City, State, Zip Code) |(include City and State) | | |

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|Second Address | | | |

| | |What was the amount of rent you paid per month? |$ |

| | |Is your name on the lease agreement? |Yes |No |

| | |Did anyone else live with you other than your spouse and/or|Yes |No |

| | |children? | | |

| | |Did anyone help you with paying the rent? |Yes |No |

| | |Is your rent subsidized (Section 8, etc)? |Yes |No |

| CONTINUE TO NEXT PAGE |

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EVERYONE ELSE - Are you? (Circle One)

|Homeless |Homeless by Choice |Staying with Family/Friends |Living in a Shelter |Adult Foster Care |Transitional Housing |

| CONTINUE TO NEXT PAGE |

|Check the school district in which you live. |Home Heating Credit |Other Household Information |

|Corruna |78100 |How do you heat your home? (Circle) |Did you, your spouse, or other family member receive |

|Durand |78030 |Electric | |LP Gas |SSI in 2020? (NOTE: This is not Social Security.) |

|Flushing |25120 |Fuel Oil | |Natural Gas |

|Morrice |78060 |Yes | |

|Perry |78080 |What did you pay for heat in 2020 and/or |State SSI in 2020? (Maximum of $42 per quarter in 2020) |

|Swartz Creek |25180 |the amount shown on your Utility Bill for | |YES |

| | |Amount appears on your December 2020, January |Tax Payer: |$ |

| | |Or February 2020 Utility Bill. |Other: |$ |

| | |Is the Utility Bill currently in your name? |Did you receive Child Support in 2020? |

| | |Yes | |

| | | |YES |NO |$ |

|City/Local Taxes |Auto/Vehicle Insurance |Did your household receive food stamps (FAP)? |

|Did you live or work in any of the following |How many vehicles did you have that were registered AND INSURED |YES |NO |$ |

|Cities? YES NO |in the state of Michigan in 2020? | | | |

|If Yes, circle and fill out City Intake Form | | |Did you and/or your spouse pay for any medical insurance |

| | | |or HMO premiums during 2020?(not including Medicare) |

|Albion Ionia | |YES |NO |$ |

|Battle Creek Jackson | | | | |

|Benton Harbor Lansing | | | | |

|Big Rapids Lapeer | | | | |

|Detroit Muskegon | | | | |

|East Lansing Muskegon Heights | | | | |

|Flint Pontiac | | | | |

|Grand Rapids Port Huron | | | | |

|Grayling Portland | | | | |

|Hamtramack Saginaw | | | | |

|Highland Park Springfeld | | | | |

|Hudson Walker | | | | |

| |If known, amount of PIP: $ |Did you have any other sources of non- taxable income? |

| |ADDITIONAL NOTES FOR TAX PREPARER: |Describe | |Amount | |

| | | |$ |

| | | |$ |

| | | |$ |

| | |NAME and CONTACT NUMBER of Intake person if Virtual |

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