13614-C Intake/Interview and Quality Review Sheet

Department of the Treasury – Internal Revenue Service

Form 13614-C
(September 2008)

OMB # 1545-1964

Intake/Interview & Quality Review Sheet

You (and Spouse) will need:

•
•
•

•
•
•

Proof of Identity
Social Security Card or Individual Tax
Identification Number (ITIN) letter for all
individuals to be listed on the return

•

Copies of ALL W-2, 1098, 1099 forms

Amounts of any other income
Child care provider’s identification number
Amounts/dates of estimated or other tax
payments made, etc.
Bank documents showing routing and account
numbers if requesting direct deposit/debit

Part I: Taxpayer Information
1. Your First Name

M.I.

3. US Citizen or Resident Alien
Yes

Yes

7. Spouse’s First Name
9. US Citizen or Resident Alien
Yes

M.I.

No

Yes

13. Address

No
8. Date of Birth
(mm/dd/yyyy)

No

Yes

No

Apt # City

State Zip Code
15. Could you or your spouse be claimed as a dependent
on the income tax return of any other person?

)

Yes

e-mail:
16. On December 31 st
Single
a. Were you:

6. Occupation

11. Totally and Permanently Disabled 12. Occupation

14. Phone Number and e-mail address
Phone: (

Yes

Last Name

10. Legally Blind

No

(mm/dd/yyyy)

5. Totally and Permanently Disabled

4. Legally Blind

No

2. Date of Birth

Last Name

Legally Married

Separated

No

Divorced

Widowed

b. If married, did you live with your spouse during any part of the last six months of the year?

Yes
(mm/dd/yyyy)

c. Is your spouse deceased? If yes, provide the date of death.

No

Part II. Family and Dependent Information – Do not include you or your spouse.
Print the name of everyone who lived in your home and outside your home that you supported during the year.
Name
(first, last)

Date of Birth
mm/dd/yyyy

Relationship to you
(son, daughter, etc.)

Number of
months person
lived with you
last year

US Citizen,
Resident of US,
Canada or Mexico
(yes or no)

Is the dependent
a full time
student?
(yes or no)

(a)

(b)

(c)

(d)

(e)

(f)

Paperwork Reduction Act Notice
The Paperwork Reduction Act requires that the IRS display an OMB control number on all public information requests. The OMB Control Number for this study is 1545-1964.
Also, if you have any comments regarding the time estimates associated with this study or suggestion on making this process simpler, please write to the Internal Revenue
Service, Tax Products Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW, Washington, DC 20224.

Catalog Number 52121E

Form 13614-C (9-2008)

Please Complete Page 2, except Part V. A Certified Volunteer will confirm the information with you.

COMMON INCOME AND EXPENSES
Part III. Income – Did you (or your spouse) receive:
Yes
Yes

No
No

Yes
Yes
Yes

No
No
No

Yes
Yes

No
No

Yes
Yes
Yes

No
No
No

Yes
Yes

No
No

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

Wages or Salary (include W-2s for all jobs worked during the year)
Tip income
Interest/Dividends from: checking or savings account, bonds, CDs, or brokerage account
State tax refund (may be taxable if you itemized last year)
Self Employment Income - business, farm, hobby, 1099-Misc or any earned income not
reported on W-2
Alimony income
Sale of Stock, Bonds or Real Estate
Disability income
Pensions, Annuities, and/or IRA distributions
Unemployment (1099-G)
Social Security or Railroad Retirement Benefits (1099-SSA or RRB)
Other Income: Identify

Part IV. Expenses – Did you (or your spouse) make or have:
Yes
Yes

No
No

Yes
Yes

No
No

Yes
Yes

No
No

Yes

No

Yes
Yes

No
No

1.
2.
3.
4.
5.
6.
7.
8.
9.

Alimony payments (if yes, you must provide the name and SSN of the recipient)
Contributions to IRA or other retirement account
Educational expenses for you, your spouse and/or dependents
Un-reimbursed medical expenses
Home mortgage payments (interest and taxes – see Form 1098)
Charitable contributions
Child/dependent care expenses that allow you (and your spouse - if married) to work
Any estimated tax payments for this tax year
Was EIC previously disallowed? (if yes, you may not be eligible for EIC)

Part V. For Completion by a Certified Volunteer
Volunteer Preparer Instructions: You must conduct a thorough interview to complete an accurate return. This
Intake/Interview Sheet is the start of your conversation with the taxpayer. Use the decision trees in Publication 4012,
Volunteer Resource Guide, while discussing the questions on this form. Remember to ask for all documentation.
Update the Intake/Interview Sheet with any changes identified during your interview. Confirm all information with
the taxpayer.
Yes

No

Yes
Yes

No
No

Yes
Yes

No
No

Yes

No

1.
2.
3.
4.
5.
6.
7.

Did any of these dependents file a joint return for this tax year?
Can anyone else claim any of these dependents on their income tax return?
Did any dependent on the return provide more than 50% of their own support?
Were any of these dependents permanently and totally disabled last year?
Did the taxpayer provide over half the support for each of these dependents?
Based on the interview, how many individuals qualify as dependents for this return?
Based on the interview, does the taxpayer qualify for EIC?

Based on the interview, the filing status of the taxpayer is:

Single

MFJ

MFS*

HOH

QW

*If MFS, then spouse’s name and SSN should be included on the tax return.

Did the taxpayer receive an Economic Stimulus Payment last year?
Yes

No

If yes, how much?

Catalog Number 52121E

Page 2

Form 13614-C (9-2008)

Interview Notes

Quality Reviewer, please complete Page 4
Quick & Easy Access to Tax Help & Forms

www.irs.gov
Tax Information & Assistance: 1-800-829-1040
Forms & Publications: 1-800-829-3676
Tele-Tax Information Line: 1-800-829-4477
Taxpayer Advocate: 1-877-777-4778

Catalog Number 52121E

Page 3

Form 13614-C (9-2008)

Quality Review
This form is used to Quality Review the completed tax return based on the Intake/Interview Sheet,
the documents provided for the return preparation, and a conversation with the taxpayer.

• Involve the taxpayer in the Quality Review process.
• Complete this form prior to obtaining the taxpayer’s signature on required tax forms.
• Compare the completed return with the Intake/Interview Sheet and all supporting documents.
Quality Reviews complete the Quality Process and help ensure an accurate return.

Verifying the Return

Check each item only when you verify that the review step is complete.

1.

Yes

No

A completed Intake/Interview Sheet was used to prepare this tax return.

2.

Yes

No

Name(s) and SSNs/ITINs for taxpayer(s) match the supporting documents.

3.

Yes

No

The taxpayer(s) address and Date of Birth match the Intake/Interview Sheet and have
been confirmed with the taxpayer.

4.

Yes

No

Filing status was correctly determined and is notated on the Intake/Interview Sheet.

5.

Yes

No

Dependent information is correctly shown including names, SSNs/ITINs, and DOBs.

6.

Yes

No

All income indicated on the Intake/Interview Sheet and W-2s/1099s is shown.

7.

Yes

No

Any Adjustments to Income are correctly reported.

8.

Yes

No

The completed return reflects the correct standard deduction unless itemized deductions
were used. If itemized deductions were used, the Schedule A has been completed
accurately based on supporting documents.

9.

Yes

No

The non-refundable credits have been correctly reported.

10.

Yes

No

All payments from W-2s and F1099’s and estimated tax payments are correct.

11.

Yes

No

The refundable credits are correctly reported including the EIC determination based on
the information provided.

12.

Yes

No

If direct deposit or debit was elected, information on the return matches the taxpayer’s
checking/saving account and routing information.

Finishing the Return

Check the appropriate box once you have confirmed the steps have been taken.

E-File: Verify correct DCN and SIDN is printed on Form 8879. Obtain taxpayer signature and provide a copy
of the return for their files. Retain original signed Form 8879 with the Forms W-2’s and 1099’s attached.
Paper: Verify the correct SIDN is printed on the return. Attach Forms W-2’s and 1099’s to the return.
Obtain taxpayer signature and provide the signed return, a copy of the return, and the correct processing
center mailing address to the taxpayer.
All taxpayer questions/issues about the completed return have been answered.
Catalog Number 52121E

Page 4

Form 13614-C (9-2008)