Questionnaire
To get started please completely fill out the following assessment questionnaire.
All information collected will always remain confidential.

Claimant Information (Person with the Disability)


Full Name
Birthdate
Address
Primary Phone
Secondary Phone
Email
Confirm Email
Preferred Contact Time
Preferred Contact Method
How did you hear about us?
Current marital status
Net Income
Source of Income
Have you claimed bankruptcy?
If you claimed bankruptcy, what year?



Information about the person claiming the disability amount
If different than Claimant

Full Name
Relationship to claimant
Phone #
Email



Disability Description

Please select all that apply

If the disability is not listed above please enter it here.

Do you receive life-sustaining therapy? (Insulin pump, dialysis, etc.)
List any therapies or medications used frequently
Additional information you feel should be added




All the information I have provided in this questionnaire is accurate and truthful.


Disability Tax Results has permission to contact me and follow up on the submitted questionnaire.