Form 13614-C Intake/Interview and Quality Review Sheet

Department of the Treasury – Internal Revenue Service

Form 13614-C
(Rev. 8- 2009)

Intake/Interview & Quality Review Sheet

OMB # 1545-1964

Section A. Page 1 and Page 2 to be completed by Taxpayer
Thank you for allowing us to prepare your tax return. It is very important for you to provide the information on this form to
help our certified volunteer preparer in completing your return. If you have any questions please ask.
You will need your:
• Tax information such as W-2s, 1099s, 1098s.
• Social security cards or ITIN letters for you and all persons on your tax return.
• Proof of Identity (such as drivers license or other picture ID).

Part I. Your Personal Information
1. Your First Name

M. I.

Last Name

2. Spouse’s First Name

M. I.

Last Name

3. Mailing Address

Apt#

Are you a U.S. Citizen?
Yes
No
Is spouse a U.S. Citizen?
Yes
No
State Zip Code

City

4. E-mail

Phone

5. Your Date of Birth
9. Spouse’s Date of Birth

6. Your Occupation
10. Spouse’s Occupation

7.
8.
11.
12.

Are you Legally Blind
Totally and Permanently Disabled
Is Spouse Legally Blind
Totally and Permanently Disabled

13. Can your parents or someone else claim you or your spouse on their tax return?

Yes

No

Single
Married: Did you live with your spouse during any part of the last six months of 2009?

Yes

Yes
Yes
Yes
Yes

No
No
No
No

Part II. Family and Dependent Information
1. As of December 31, 2009 your marital status was:
No

Divorced or Legally Separated: Date of final decree or separate maintenance agreement:
Widowed: Date of spouse’s death:
2. List the name of everyone below who lived in your home and outside your home that you supported during the year.
Name (first, last)
Do not enter your name or
Spouse’s name below.

Date of Birth
(mm/dd/yy)

Relationship to you
(e.g. son, mother,
sister)

Number
of months
lived in
your
home

US Citizen or
resident of the
US, Canada
or Mexico
(yes/no)

Married
as of
12/31/09
(yes/no)

Fulltime
student
(yes/no)

Received
more than
$3650 in
income
(yes/no)

(a)

(b)

(c)

(d)

(e)

(f)

(g)

(h)

If additional space is needed please use page 4 and check here
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

Please continue on Page 2

Catalog Number 52121E

Form 13614-C (Rev. 8-2009)
1

Section A. To be completed by Taxpayer (continued)

Part III. Life Events (Check Yes or No to all questions below)
Yes
Yes

No
No

1. If you are due a refund, would you like a direct deposit?
2. If you have a balance due, would you like a direct debit?

During 2009 did you (or your spouse if filing a joint return):
Yes

No

Yes
Yes
Yes

No
No
No

Yes
Yes
Yes
Yes
Yes
Yes

7. Are you or your spouse a government retiree?
No
No
8. Purchase and install energy efficient home items? (such as windows, furnace, insulation, etc.)
9. Live in an area that was affected by a natural disaster? If yes, where?
No
No 10. Pay college tuition for yourself, your spouse, or your dependents?
No 11. Have any student loans?
No 12. Make estimated tax payments or apply last year’s refund to your 2009 tax?
If yes, amount

3. Buy a brand new vehicle? If yes, date of purchase:
4. Buy a home? If yes, closing date:
5. Have a foreclosure or did the bank cancel any part of your mortgage loan?
6. Receive an Economic Recovery Payment from Social Security Administration, Railroad Retirement
Board, or Veterans Administration? If yes, how much?
$250
$500

Part IV. Income – In 2009, did you (or your spouse) receive: (Check Yes or No to all questions below)
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

1. Wages or Salary
No
2. Tip Income
No
3. Scholarships
No
4. Interest/Dividends from: checking or savings accounts, bonds, CDs, brokerage, etc.
No
5. State Tax Refund: If yes, did you itemize your deductions last year?
No
Yes
No
6. Self-Employment Income (such as earnings from contract labor, small business, hobby, etc.)
No
No
7. Alimony Income
No
8. Proceeds (or loss) from the sale of Stocks, Bonds or Real Estate (including your home)
No
9. Disability Income
No 10. Pensions, Annuities, and/or IRA Distributions
No 11. Unemployment Compensation
No 12. Social Security or Railroad Retirement Benefits
No 13. Income from Rental Property
No 14. Other Income: (gambling, lottery, prizes, awards, jury duty, etc.) Identify:

Part V. Expenses – In 2009 Did you (or your spouse) pay: (Check Yes or No to all questions below)
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No
No
No

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

Alimony: If yes, do you have the recipient’s SSN?
Yes
No
Contributions to IRA, 401 k, or other retirement account, including employer retirement account
Educational expenses (such as a computer, books, etc.)
Classroom supplies if you are a teacher
Medical expenses
Home mortgage interest
Real estate taxes for your home
Charitable contributions
Child/dependent care expenses that allowed you and your spouse, to work or to look for work

STOP HERE!
Thank you for completing this form.
Please give this form to the certified volunteer preparer for use in preparing your return.
Catalog Number 52121E

Form 13614-C (Rev. 8-2009)
2

Section B. For Certified Volunteer Preparer Completion
and Reminder

Section C. To be completed by
a Certified Quality Reviewer

Remember: YOU are the link between the taxpayer’s information and a
correct tax return! Verify the taxpayer’s information on pages 1 & 2. Consult
Publications 4012 & 17 as well as other tools. Make notes on this form as
needed, especially when the taxpayer’s information is missing or incorrect.
Must be completed by Certified Volunteer Preparer

Check each item after reviewing the tax
return and verifying that it reflects
correct tax law application to the
information provided by the taxpayer.

Yes

No

N/A

Yes

No

2. Were any of the persons listed in Part II, question 2,
totally and permanently disabled? If yes, which ones:

No

3. Did any of the persons listed in Part II, question 2
provide more than half of their own support? If yes,
which ones:

N/A

Yes
N/A

Yes

1. Section A & B of this form
are complete.
2. Taxpayer’s identity, address
and phone number was
verified.
3. Names, SSN or ITINs, and
dates of birth of taxpayer,
spouse and dependents
match the supporting
documents.
4. Filing Status is correctly
determined.
5. Personal and Dependency
Exemptions are entered
correctly on the return.

No

4. Did the taxpayer provide more than half the support for
each of the persons in Part II, question 2? If no, which
ones:

No

5. Did the taxpayer pay over half the cost of maintaining
a home for any of the persons in Part II, question 2? If
yes, which ones:

7. Any Adjustments to Income
are correctly reported.

9. All credits are correctly
reported.

N/A

Yes

1. Can anyone else claim any of the persons listed in Part
II, question 2, as a dependent on their return? If yes,
which ones:

N/A

Yes

No

6. Was the taxpayer’s Earned Income Credit (EIC)
disallowed in a prior year? If yes, for which tax
year

Yes

No

7. Does the taxpayer qualify for the first-time homebuyers
credit?

Reminders
Use Publication 4012 & 17 in making tax law determination.
• Earned Income Credit (EIC) with children - the qualifying child cannot
be older than the taxpayer.
• Qualifying Child/Qualifying Relatives - Rules have changed.
• There are special rules for children of divorced, separated, or never
married parents.
New Tax Benefits and credits under ARRA 2009
• Vehicle Sales Tax
• Economic Recovery Payment
• First-time homebuyer Credit
• Energy Efficiency
• Education Expense
• Increase EITC & Child Tax Credit
• Unemployment benefits

6. All income shown on source
documents and noted in
Sections A, part IV is included
on the tax return.

8. Standard, Additional or
Itemized Deductions are
correct.

10. Withholding shown on Forms
W-2,1099 and Estimated
Tax Payments are correctly
reported.
11. If direct deposit or debit was
elected checking/saving
account and routing
information match the
supporting documents.
12. Correct SIDN is shown on the
return.

Making Work Pay Tax Credit
• Does the taxpayer need to adjust their W-4/W-4P withholding?
Catalog Number 52121E

Form 13614-C (Rev. 8-2009)
3

Additional Taxpayer’s Information:

Additional Tax Preparer Notes:

Catalog Number 52121E

Form 13614-C (Rev. 8-2009)
4