1 Do you live in Connecticut? ---Select One--- No Yes
2 How old are you?
3 What is your residency status? ---Select One--- US Citizen Permanent Resident Asylee/Refugee Other
4 Do you have a spouse or partner living with you? ---Select One--- No Yes
5 How many children (18 and under) live in your house?
5a Are any of the children living with you under 15 years old? ---Select One--- No Yes
5b Are any of the children living with you under 13 years old? ---Select One--- No Yes
5c Are any of the children living with you under 5 years old? ---Select One--- No Yes
6 Besides your spouse/partner, how many adults living with you do you claim as dependents on your tax return?
7 Do you, or any adult living with you have any kind of disability? ---Select One--- No Yes
8 Is anyone in your household currently pregnant or was pregnant in last 12 months? ---Select One--- No Yes
9 How will you be filing your taxes this year? ---Select One--- Single Jointly Not Filing
10 Are you currently employed? ---Select One--- No Yes
10a How much money per pay period do you make before taxes and other deductions?
10b How often do you get paid? ---Select One--- Weekly Biweekly Twice Monthly Monthly Annually
10a Are you in an approved training activity? ---Select One--- No Yes
11 Does your household have income from sources other than employment? ---Select One--- No Yes
11a About that other income: how much is it?
11b How often? ---Select One--- Weekly Biweekly Twice Monthly Monthly Annually
12 Is your spouse or partner currently employed? ---Select One--- No Yes
12a How much money does your spouse/partner make before taxes and other deductions are taken out?
12b How often does your spouse/partner get paid? ---Select One--- Weekly Biweekly Twice Monthly Monthly Annually
12a Is he/she in an approved training activity? ---Select One--- No Yes
Any questions? Dial 2-1-1 from anywhere in the State of Connecticut. The call is free.
211 Navigator
