Form 13614-T Form 13614-T Telephone Excise Tax Refund

Telephone Excise Tax Refund
1040EZ-T INTAKE SHEET

Form 13614-T
January-2007

OMB # 1545-2057

All information will be treated confidentially • Return Preparation services are free.

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Did you pay for long distance telephone service billed after February 28, 2003, and before, August 1, 2006?
If no, STOP - You do not qualify for the Telephone Excise Tax refund.

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Did you receive or have you requested a refund of the taxes you paid from your long distance service provider?
If yes, STOP - You do not qualify for the Telephone Excise Tax refund.

•

Can you be claimed as a dependent on the income tax return of any other person for 2006?
If yes, you must file Form 8913 to claim the Actual Taxes Paid.

•

Have you or will you file a 2006 Federal Income Tax return?
If yes, do not complete the 1040EZ-T; you may request the telephone tax refund on your Form 1040.

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Did you have wages or self-employed income in 2006?
If yes, do not complete the 1040EZ-T; you may be eligible for not only the refund but other benefits on a Form 1040.

PERSONAL INFORMATION
Your First Name

M.I.

Last Name

SSN or ITIN

Spouse’s First Name

M.I.

Last Name

SSN or ITIN

Address

Apt #

Phone Numbers: Daytime

City

State Zip Code
Cell

Evening

Personal and Dependent Information
List all persons, including yourself, for whom you provided support in 2006:
Person 1

Person 2

Person 3

Person 4

Name
Birth Date
Relationship to you (son, daughter, parent, etc.)
Number of months this person lived in your home
during 2006
Is this person a US Citizen, US Resident, or
Resident of Mexico or Canada?
Did you provide more than 50% support for this
person in 2006?
Did this person provide less than 50% of their
own support in 2006?
Was this person’s income less than $3,300 in 2006?

If you had Earned Income in 2006, you may be eligible for the
Earned Income Tax Credit (EITC) or other Credits
Form 13614-T (1-2007)

Catalog Number 49433V

Department of the Treasury — Internal Revenue Service