Wufoo

Personal Information
1) Last Name: *
2) First Name: *
3) Middle Name:
4) Other Names:
5) Male or Female?
6) Date of Birth:
7) Cell phone number: ### - ### - ####
8) Work phone number: ### - ### - ####
9) Email
10) Mailing Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
11) Occupation (At Time of Arrest):
12) Annual income?
13) Current Employment Status:
14) Married prior to J6?
Yes No
a) Name of Spouse First Last
b) Is Spouse a J6 Defendant?
Yes No
15) Children? If so, full names and date of birth

a)
Date MM / DD / YYYY
b)
Date MM / DD / YYYY
c)
Date MM / DD / YYYY
d)
Date MM / DD / YYYY
e)
Date MM / DD / YYYY
f)
Date MM / DD / YYYY
g)
Date MM / DD / YYYY
16) Marital status:
Maried Divorced Single
17) Before J6, what did you do to earn a living?
18) What was your annual income prior to J6?
19) Before J6, did you own your own home?
Yes No
20) What value was that home?
21) Social Security Number: *
22) Military Service: (Yes/No)
Yes No
23) If yes, provide branch, rank, and service details.
24) Prior to J6, Disability Status: (Yes/No)
Yes No
a) If yes, provide details and how the case impacted your condition.
b) Upload Supporting Documents:

i) Identification documents

Drivers license or state ID
Passport
Military ID
ii) Employment records
iii) Tax returns (past five years before January 6th and four years after)

2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
iv) Other relevant documents
v) Photos, videos, or recordings related to the case
vi) Any contracts, agreements, or financial losses due to the case
25) Have you been publicly defamed or misrepresented in media prior to J6?
Yes No
a) If yes, provide details and upload supporting documents.
URL
URL
b) Have you been surveilled or monitored by law enforcement before J6? (Yes/No)
Yes No
i) If yes, describe incidents and provide supporting evidence.
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Wufoo

Personal Information