Work With Us
ERC Pre-Qualification
FAQ
Class Action Settlement
Updates
Contact
About
Work With Us
Menu Item
SETC Internal Intake Form
FOR INTERNAL USE ONLY.
Step
1
of
5
20%
Name
First
Last
Email
Phone
By providing & telephone number and submitting the form you are consenting to be contacted by SMS text message. Message & data rates may apply. Reply STOP to opt out of further messaging.
Did you have a child in your care at any point in 2020 or 2021?
Yes
No
I'm not sure
This includes either a child under 18 or an adult child with physical or mental disabilities. Answer yes if you were taking care of a child full-time/their guardian. Includes: grandparents, step-parents, temporary guardians or acting in "loco parentis".
What is your net self-employed income in 2019?
Put in the number listed on your tax return if you have it, otherwise put in your best estimate.
What is your net self-employed income in 2020?
Put in the number listed on your tax return if you have it, otherwise put in your best estimate.
What is your net self-employed income in 2021?
Put in the number listed on your tax return if you have it, otherwise put in your best estimate.
Did you receive any W-2 income in 2020 or 2021 in addition to your other 1099/self-employed type income?
Yes
No
Did you have a spouse with self-employed income in 2020 or 2021?
Yes
No
At any point from April 1 through December 31, 2020 were you unable to perform services as a self-employed individual because you were ANY of the following:
Subject to a federal, state, or local quarantine or isolation order related to COVID-19.
Advised by a health care provider to self-quarantine due to concerns related to COVID-19.
Experiencing any symptoms of COVID-19 and seeking a medical diagnosis.
Sick10.1A
No
Yes, for part of this period
Yes, for this entire period
Please select the dates:
mm/dd/yyyy
At any point from January 1 through March 31, 2021 were you unable to perform services as a self-employed individual because you were ANY of the following:
Subject to a federal, state, or local quarantine or isolation order related to COVID-19.
Advised by a health care provider to self-quarantine due to concerns related to COVID-19.
Experiencing any symptoms of COVID-19 and seeking a medical diagnosis.
Sick10.1B
No
Yes, for part of this period
Yes, for this entire period
Please select the dates:
mm/dd/yyyy
At any point from April 1 through September 30, 2021 were you unable to perform services as a self-employed individual because you were ANY of the following:
Subject to a federal, state, or local quarantine or isolation order related to COVID-19.
Advised by a health care provider to self-quarantine due to concerns related to COVID-19.
Experiencing any symptoms of COVID-19 and seeking a medical diagnosis.
Sick10.1C
No
Yes, for part of this period
Yes, for this entire period
Please select the dates:
mm/dd/yyyy
At any point from April 1 through December 31, 2020 were you unable to perform services as a self-employed individual because you were ANY of the following:
Caring for an individual who was subject to a federal, state, or local quarantine or isolation order related to COVID-19.
Caring for an individual who was advised by a health care provider to self-quarantine due to concerns related to COVID-19.
Caring for a child because the school or place of care for that child was closed or the childcare provider for that child was unavailable due to COVID-19 precautions.
Sick10.2A
No
Yes, for part of this period
Yes, for this entire period
Please select the dates:
mm/dd/yyyy
At any point from January 1 through March 31, 2021 were you unable to perform services as a self-employed individual because you were ANY of the following:
Caring for an individual who was subject to a federal, state, or local quarantine or isolation order related to COVID-19.
Caring for an individual who was advised by a health care provider to self-quarantine due to concerns related to COVID-19.
Caring for a child because the school or place of care for that child was closed or the childcare provider for that child was unavailable due to COVID-19 precautions.
Sick10.2B
No
Yes, for part of this period
Yes, for this entire period
Please select the dates:
mm/dd/yyyy
At any point from April 1 through September 30, 2021 were you unable to perform services as a self-employed individual because you were ANY of the following:
Caring for an individual who was subject to a federal, state, or local quarantine or isolation order related to COVID-19.
Caring for an individual who was advised by a health care provider to self-quarantine due to concerns related to COVID-19.
Caring for a child because the school or place of care for that child was closed or the childcare provider for that child was unavailable due to COVID-19 precautions.
Sick10.2C
No
Yes, for part of this period
Yes, for this entire period
Please select the dates:
mm/dd/yyyy
At any point from April 1 through December 31, 2020 were you unable to perform services as a self-employed individual because of certain coronavirus-related care you provided to a child whose school or place of care was closed OR your childcare provider was unavailable for reasons related to COVID-19
CC50A
No
Yes, for part of this period
Yes, for this entire period
Please select the dates:
mm/dd/yyyy
At any point from January 1 through March 31, 2021 were you unable to perform services as a self-employed individual because of certain coronavirus-related care you provided to a child whose school or place of care was closed OR your childcare provider was unavailable for reasons related to COVID-19
CC50B
No
Yes, for part of this period
Yes, for this entire period
Please select the dates:
mm/dd/yyyy
At any point from April 1 through September 30, 2021 were you unable to perform services as a self-employed individual because of certain coronavirus-related care you provided to a child whose school or place of care was closed OR your childcare provider was unavailable for reasons related to COVID-19
CC60
No
Yes, for part of this period
Yes, for this entire period
Please select the dates:
mm/dd/yyyy
Are you delinquent on any of the following items?
Any Federal taxes
State income taxes
Child support
Student loans or other delinquent federal nontax obligations
Delinquency Status
Yes
No
Please list the delinquent items and how much is owed:
Menu
