Home Owners and Mobile Home Owners

STATE INTAKE FORM (PLEASE PRINT)

Your Name ______

Home Owners and Mobile Home Owners

Did you bring your 2017 property tax statements with you?
YesNo / 2017 Taxable Value $ / Mobile Home Owners
2017 Summer Taxes $
2017 Winter Taxes $ / What is the amount of your lot rent per month? $
Who do you pay your lot rent to?
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Renters Only

Where did you live during 2017?
(Street Address, City, State, Zip Code)
First Address / What was the Landlord’s Name?
(include City and State) / How many months did you live here during 2017?
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 children? / Yes / No
Did anyone help you with paying the rent? / Yes / No
Is your rent subsidized (Section 8, etc)? / Yes / No
Where did you live during 2017?
(Street Address, City, State, Zip Code)
Second Address / What was the Landlord’s Name?
(include City and State) / How many months did you live here during 2017?
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 children? / Yes / No
Did anyone help you with paying the rent? / Yes / No
Is your rent subsidized (Section 8, etc)? / Yes / No
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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
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Check the school district in which you live. / Home Heating Credit / Other Household Information
Dansville / 33040 / How do you heat your home? (Circle) / Did you, your spouse, or other family member receive
East Lansing / 33010 / Electric / LP Gas / SSI in 2017? (NOTE: This is not Social Security.)
Haslett / 33060 / Fuel Oil / Natural Gas / YES / NO
Holt / 33070 / Kerosene / Wood/Coal/Pellets / Tax Payer: / $
Okemos / 33170 / Is your heat included in your rent? / Tax Payer: / $
Lansing / 33020 / Yes / No / Other: / $
Okemos / 33170 / If no, please answer the question below: / Did you, your spouse, or other family member receive
Waverly / 33215 / What did you pay for heat in 2017 and/or / State SSI in 2017? (Maximum of $42 per quarter in 2017)
Williamston / 33230 / the amount shown on your Utility Bill for the / YES / NO
Home Heating Credit? (The amount / Tax Payer: / $
appears on your December 2017, January or / Tax Payer: / $
February 2017 Utility Bill.) $ / Other: / $
Is the Utility Bill currently in your name? / Did you receive Child Support in 2017?
Yes / No / YES / NO / $
If No, whose name is the Utility Bill in? / Did you receive Cash Assistance from DHS in 2017?
YES / NO / $
City/Local Taxes / Did your household receive food stamps (FAP)?
Did you live or work in any of the following / Employment dates for all jobs in 2017: / YES / NO / $
Cities? YES NO / Employed From: / Did you and/or your spouse pay for any medical insurance
Flint / Employed To: / or HMO premiums during 2017?(not including Medicare)
Grand Rapids / As a city nonresident, did you work both / YES / NO / $
Jackson / Inside and outside of the city? YES NO / Did you have any other sources of non- taxable income?
Lansing / If YES, how many days or hours did you / Describe / Amount
Addresses of all work locations: / work for each employer in 2017? / $
$
$
If YES, how many days or hours actually / How many vehicles do you own that are licensed and
worked in the city? / insured in Michigan? (car, truck, motorcycles, boat, etc.)
Use additional paper if needed.