How to Start a Volunteer Income Tax Assistance Site
Client Survey
Download Client Survey PDF
Dear Tax Preparation Client,
In order to allow us to determine the success of the New Hampshire EITC campaign and better meet the needs of our clients, please complete the brief survey below and return it to the tax preparer that assisted you today. All questions are completely voluntary, and all your answers are anonymous. If you have any questions, the person who gave you this form will be more than happy to assist you. Thank you so much for making use of our services, and please encourage your friends, family, and coworkers to visit us as well!
With regards,
Everyone with the New Hampshire EITC Campaign
Please circle answers to the questions below:
1.) What is your ethnicity? (Please circle all that apply)
AA: African-American
NA: Native American
AS: Asian/Pacific Islander
OT: Other
CA: Caucasian
RE: do not wish to answer
LA: Latino/Hispanic
2.) Do you have a bank account?
CH: checking
SA: savings
BO: both
NB: No, but would like one
99: do not wish to answer
NO: No, and not interested
3.) What is your preferred language?
EN: English
SP: Spanish
4.) How did you have you taxes done last year?
0: Didn’t file last year
1: Here
2: Another free place like this
3: Did my own
4: Family or friend did them for free
5: Went to a commercial preparer like H&R or JacksonHewitt and got an instant refund
6: Went to a commercial preparer like H&R Block or Jackson-Hewitt but didn’t go for the instant refund
7: Paid someone else and got an instant refund
8: Paid someone else but didn’t go for the instant refund
99: do not wish to answer
5.) How did you hear about this place?
1: I came here last year
2: I heard an ad on radio or TV
3: I saw a flyer or something in the paper
4: I walked by
5: Friend or family member told
6: Someone else told me
7: Not sure
99: do not wish to answer
6.) Did you receive public benefits in 2005 (like Food Stamps, TANF, medical assistance, or Health Kids Program insurance coverage?
1: yes
2: don’t recall
3: No, but would like to apply
4: No, and not interested
99: do not wish to answer
7.) What is your gender?
1: male
2: female
FOR EITC VOLUNTEER USE ONLY
(1) Date of Service:
(2) Time of Service:
(3) Tax Year:
(4) VITA Site Name:
(5) Name and Street Address of Tax Preparation Site (we need the street address of your site since this is the way that we will identify each specific site on the
database):
(6) First and Last Name of Preparer:
Please indicate the amount of each one of the following:
(7) EITC:
(8) Child Tax Credit:
(9) Other Credits:
(10) Refund:
(11) Software Used (Circle one):
(A) Taxwise
(B) Other
(12) Please indicate other services that were rendered to the client. (Circle all that apply)
(A) Referral to Financial Literacy Training and/or Resources
(B) Referral to Individual Development Account Program
(C) Opening a Checking or Other Banking Account
(D) Other – Please specify:
(13) Was client referred to other tax preparation services?
a. No
b. Yes, income too high for free filing and wanted to go elsewhere
c. Yes, had received IRS notices and needed additional help
d. Yes, return too complex for our site for other reasons and needed additional help.
e. Other
Please enter information from this survey at http://_______________________________
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