SWEF Participant Intake Form

1
Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Date
Year
Month
Day
3
Phone Number* This field is required.
Please enter a valid phone number.
4
Email* This field is required.
example@example.com
5
Current Housing Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Case Manager/Staff Contact Name* This field is required.
7
Case Manager/Staff Contact Phone Number* This field is required.
Please enter a valid phone number.
8
Housing & Transition Status* This field is required.
Emergency Shelter
Transitional Housing
Temporary Housing
Permanent Supportive Housingr
Rapid Re-housing
Domestic Violence Shelter
9
Expected Transition Timeline* This field is required.
0-3 Months
3-6 Months
6-12 Months
Not Sure
10
Financial Education Goals* This field is required.What areas would you like support with? (Check all that apply)
Understanding Credit
Viewing & Understand My Credit Profile
Credit Rebuilding Strategies
Identity Theft or Fraud Issues
Tax Readiness/Filing Concerns
Budgeting & Money Management
Banking & Account Access
Planning Next Financial Steps
Other
11
Have you ever reviewed your credit report before?* This field is required.
YES
NO
12
Do You Know Your Credit Score?* This field is required.
YESNO
13
If Yes, What Is Your Credit Score
14
Have You Ever Worked With A Credit Repair Company Before? * This field is required.
YESNO
15
Do you give SWEF permission to review your credit information with you for educational and planning purposes?* This field is required.Credit reviews are used to explain information, identify issues, and support education. SWEF does not guarantee outcomes.
YES
NO
16
Do you believe your identity may have been misused or compromised?* This field is required.
YES
NO
NOT SURE
17
Have you ever experienced any of the following? (Optional)* This field is required.Select all that apply
Identity theft
Fraudulent accounts
Tax-related identity issues
Lost or stolen identification documents
Utility shut offs
Wage garnishments
Child support arears
IRS or state tax debt
Judgements or liens
Other
18
Are You Interested in SWEF Offering You Free Credit Advocacy Services?* This field is required.
YES
NO
NOT SURE
19
Have you filed taxes in the last 2 years?* This field is required.
YES
NO
NOT SURE
Type option 4
20
Have you ever received a delayed or denied tax refund?* This field is required.
YES
NO
NOT SURE
Type option 4
21
Do you currently have unfiled tax years?* This field is required.
YES
NO
NOT SURE
Type option 4
22
If Yes, What Years Are Unfiled?Select all that apply.
2025
2024
2023
2022
2021
2020
NOT SURE
23
If Yes, What Years Are Unfiled?* This field is required.
24
To Your Knowledge Do You Owe IRS Or State Taxes?* This field is required.
YESNO
25
Are You Interested in SWEF Offering You Free Tax Preparation Assistance?* This field is required.
YES
NO
NOT SURE
26
Do You Have A Bank Account
YESNO
27
Would You Like Free Assistance in Opening a Bank Account?* This field is required.
YES
NO
NOT SURE
28
What is your main financial goal within the next 6-12 months?Select All That Apply
Housing
Car
Job
Start a business
29
Are you interested in receiving follow-up support after transitioning from shelter or program services?* This field is required.
YES
NO
NOT SURE
Type option 4
30
Are You Currently Employed Or Actively Seeking Employment?
YESNO
31
Participant Services Agreement * This field is required.Purpose of Agreement-This Agreement outlines the terms under which Strategic Wealth Empowerment Foundation (SWEF), a Michigan nonprofit corporation, provides free financial empowerment services to participants. Scope of Services-SWEF provides free financial education, budget support, credit education and advocacy assistance, and free tax preparation and filing services. Services are educational and supportive in nature and do not guarantee specific outcomes. Participant Responsibilities-Participants agree to provide accurate, complete, and truthful information. Participants are responsible for reviewing all documents prepared on their behalf and making final decisions. No Fees or Compensation-All services are provided at no cost. SWEF does not receive compensation from participants. Limitation of Services-SWEF does not provide legal advice, investment advice, or representation beyond the scope described herein.
32
Limited Authorization for Credit Dispute Assistance * This field is required.Purpose of Agreement-I authorize Strategic Wealth Empowerment Foundation to assist me with preparing and submitting credit dispute correspondence based solely on information I provide and approve. Participant Control-I understand that I remain the principal party in all credit matters and that SWEF acts only as an educational advocate. Revocation-This authorization may be revoked by me at any time in writing.
33
Authorization to Access and Review Credit Reports * This field is required.Authorization-I authorize SWEF to obtain, review, and discuss my consumer credit reports for educational and advocacy purposes in accordance with the Fair Credit Reporting Act (FCRA). Use of Information-Credit information will be used solely to educate me on my credit profile and to assist with accuracy reviews and dispute preparation at my request. Duration and Revocation-This authorization is valid for six months and may be revoked in writing at any time.
34
Privacy and Data Security Acknowledgment * This field is required.Confidentiality-SWEF is committed to protecting participant privacy and maintaining confidentiality of all personal and financial information. Data Use-Information collected will be used solely for program delivery, compliance, and reporting purposes. Safeguards-SWEF uses reasonable administrative, technical, and physical safeguards to protect participant data.
35
Tax Preparation and Electronic Filing Consent * This field is required.Authorization-I authorize SWEF to prepare and electronically file my federal and Michigan income tax returns using information I provide. Accuracy and Review-I understand that I am responsible for the accuracy of all information provided and must review and approve my tax return prior to filing. Scope of Tax Services-Tax services are provided free of charge and are limited to returns within SWEF’s program scope. Complex returns may be referred to a qualified tax professional.
36
Cohort Commitment AgreementTo receive free financial services through SWEF, I understand and agree to the following:
I am required to attend all four (4) cohort classes as part of the program.
I agree to actively participate in each session and complete any required activities or follow-ups.
I understand that attendance is mandatory, and missing more than one session may result in removal from the program.
I acknowledge that SWEF services are provided at no cost through grants and community support, and my participation is required to receive these services.
I understand that SWEF provides financial education and support services only and does not guarantee specific results, including credit score increases or financial approvals.
I agree to communicate with SWEF regarding scheduling or participation issues when possible.
I consent to receive communication (phone, email, or text) related to my participation in the program.
I allow SWEF to track my progress for program improvement and reporting purposes.
37
SWEF Disqualification PolicyTo maintain the integrity of the program and ensure services are provided to committed participants, the following conditions may result in disqualification or removal from the SWEF program: Missing more than one (1) required cohort session without prior notice Repeated tardiness or leaving sessions early without valid reason Failure to complete required intake forms, documentation, or program assignments Lack of communication or unresponsiveness to SWEF outreach Providing false, misleading, or incomplete information Disruptive, disrespectful, or non-cooperative behavior during sessions Failure to follow through on agreed-upon action steps related to financial improvement Participants who are removed from the program may not be eligible to re-enroll immediately and may be required to reapply for future cohorts. SWEF reserves the right to determine participation eligibility and enforce program policies to ensure a productive and supportive environment for all participants. I understand and agree to the disqualification policy
38
Additional Information
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