Form 13614-C Intake/Interview & Quality Review Sheet

Department of the Treasury – Internal Revenue Service

Form 13614-C
(Rev. 10-2012)

OMB # 1545-1964

Intake/Interview & Quality Review Sheet

Section A. Complete Pages 1-3
You are responsible for the information on your return so please provide complete and accurate information
to the IRS certified volunteer preparer. If you have any questions please ask your preparer.
You will need your:
• Tax information such as Forms W-2, 1099, 1098.
• Social security cards or ITIN letters for you and all persons on your tax return.
• Picture ID (such as a valid driver’s license or other government issued ID for you and your spouse, if applicable).

Part I. Your Personal Information
1. Your First Name

M. I. Last Name

Are you a U.S. Citizen?
Yes
No

2. Your Spouse’s First Name

M. I. Last Name

Is your spouse a U.S. Citizen?
Yes

Apt#

3. Mailing Address

City

4. Contact Information
Phone:

Cell Phone:

5. Your Date of Birth

6. Your Job Title

9. Your Spouse’s Date of Birth

State

No

Zip Code

E-mail:
Are you:

10. Your Spouse’s Job Title

13. Can anyone claim you or your spouse on their tax return?

7. Legally Blind

Yes

No

8. Totally and Permanently Disabled

Yes

No

Is Your Spouse: 11. Legally Blind
12. Totally and Permanently Disabled

Yes
Yes

No
No

Yes

No

Unsure

Part II. Marital Status and Household Information
1. As of December 31, 2012, were you?
Single
Yes

Married: Did you live with your spouse during any part of the last six months of 2012?

No

Divorced or Legally Separated: Date of final decree or separate maintenance agreement:
Widowed: Year of spouse’s death:
2. List names below of everyone who lived in your home in 2012 (other than you or spouse). Also list anyone who lived outside of
your home that you supported during 2012. If additional space is needed please check here
and list on page 3.
Name (first, last)
Do not enter your name or
spouse’s name below.
(a)

Date of Birth
(mm/dd/yy)
(b)

Relationship to you
(e.g. daughter,
son, mother, sister,
none)
(c)

Number
of months
lived in
your home
in 2012

US Citizen or
resident of US,
Canada or
Mexico in 2012
(yes/no)

Marital
Status
as of
12/31/12
(S/M)

Fulltime
Student
in 2012
(yes/no)

(d)

(e)

(f)

(g)

Received
less than
$3800
income in
2012
(yes/no)
(h)

To check the status of your REFUND visit “Where’s My Refund?” on www.irs.gov
or call 1-800-829-1954 for assistance.
Volunteers assisting with preparing your return are trained to provide high quality service and
uphold the highest ethical standards.
To report unethical behavior to IRS, email us at [email protected] or call toll free 1-877-330-1205.
Catalog Number 52121E

Form 13614-C (Rev. 10-2012)

1

Section A. Please complete – check Yes, No or Unsure to all questions below. Please ask if you need help.

Part III. Income – In 2012, did you (or your spouse) receive:
Yes No

Unsure
1. Wages or Salary? (Form W-2) If yes, how many jobs did you have in 2012?
2. Tip Income?
3. Scholarships? (Forms W-2, 1098-T)
4. Interest/Dividends from: checking/savings accounts, bonds, CDs, brokerage? (Forms 1099-INT, 1099-DIV)
5. Refund of state/local income taxes? (Form 1099-G)
6. Alimony Income?
7. Self-Employment Income? (Form 1099-MISC)
8. Cash/check payments for any work performed not reported on Forms W-2 or 1099?
9. Income (or loss) from the sale of Stocks, Bonds or Real Estate (including your home)? (Forms 1099-S, 1099-B)
10. Disability Income (such as payments from insurance, or workers compensation)? (Forms 1099-R, W-2)
11. Distributions from Pensions, Annuities, and/or IRA? (Form 1099-R)
12. Unemployment Compensation? (Form 1099-G)
13. Social Security or Railroad Retirement Benefits? (Forms SSA-1099, RRB-1099)
14. Income (or loss) from Rental Property?
15. Other Income: (gambling, lottery, prizes, awards, jury duty, etc.)? (Forms W-2 G, 1099-MISC)
Specify:

Part IV. Expenses – In 2012 Did you (or your spouse) pay:
Yes No

Unsure
1. Alimony: If yes, do you have the recipient’s SSN?
2. Contributions to a retirement account?

IRA

Yes

No

Roth IRA

401K

Other

3. Educational expenses for yourself, spouse or dependents, such as tuitions, books, fees, etc.? (Form 1098-T)
4. Unreimbursed employee business expenses (such as uniforms or mileage)?
5. Medical expenses (including health insurance premiums)?
6. Home mortgage interest? (Form 1098)
7. Real estate taxes for your home or personal property taxes for your vehicle? (Form 1098)
8. Charitable contributions?
9. Child or dependent care expenses such as day-care?
10. For supplies used as an eligible educator such as a teacher, teacher’s aide, counselor, etc.?

Part V. Life Events – In 2012 Did you (or your spouse):
Yes No

Unsure
1. Have a Health Savings Account? (Forms 5498-SA, 1099-SA, W-2 with code W in Box 12)
2. Have debt from a mortgage or credit card canceled/forgiven by a commercial lender? (Forms 1099-C, 1099A)
3. Buy, sell or have a foreclosure of your home? (Form 1099-A)
4. Have Earned Income Credit (EIC) disallowed in a prior year? If yes, for which tax year?
5. Purchase and install energy-efficient home items? (such as windows, furnace, insulation, etc.)
6. Live in an area that was affected by a natural disaster? If yes, where?
7. Receive the First Time Homebuyers Credit in 2008?
8. Pay any student loan interest? (Form 1098-E)
9. Make estimated tax payments or apply last year’s refund to your 2012 tax? If so how much?
10. Attend school as a full time student? (Form 1098-T)
11. Adopt a child?
12. File a 2011 federal tax return containing a “capital loss carryover” on Form 1040 Schedule D?
13. Become a victim of identity theft?

Presidential Election Campaign Fund: (If you check a box, your tax or refund will not change.)
You
Spouse
Check here if you, or your spouse if filing jointly, want $3 to go to this fund

Catalog Number 52121E

Form 13614-C (Rev. 10-2012)

2

Additional Information and Questions related to the preparation of your return
Many free tax preparation sites operate by receiving grant money. The data from the following questions
may be used by this site to apply for these grants. Your answers will be used only for statistical purposes.
Other than English what language is spoken in the home?
Are you or a member of your household considered disabled?

Yes

No

If you are due a refund or have a balance due:

•

Ask your preparer about Direct Deposit. It is the fastest, safest way to receive your tax refund. When you combine e-file
and direct deposit, the IRS will likely issue your refund in as few as 10 days.

•

Ask your preparer about purchasing Series I U.S. Savings Bonds with part or all of your tax refund. Savings bonds
are a safe and secure way to invest in the future. Purchase I Bonds for yourself or others in multiples of $50 and
earn interest for up to 30 years.

If you are due a refund, would you like a direct deposit?
If you are due a refund, would you like information on how to purchase U.S. Savings Bonds?
If you are due a refund, would you like information on how to split your refund between accounts?
If you have a balance due, would you like to make a payment directly from your bank account?

Yes
Yes
Yes
Yes

No
No
No
No

Additional comments:

Under no circumstances will the Internal Revenue Service tolerate discriminatory treatment of taxpayers by its employees,
or individuals who volunteer or work at Volunteer Income Tax Assistance (VITA) and Tax Counseling for the Elderly
(TCE) sites. No taxpayer shall be subject to discrimination on the basis of sex, race, color, national origin, reprisal, disability
or age in educational programs or activities supported by the Department of the Treasury – Internal Revenue Service.
Taxpayers with a disability may require a reasonable accommodation in order to participate or receive the benefits of a
program or activity supported by the Department of the Treasury – Internal Revenue Service. Site Coordinators and
Managers are responsible for ensuring that requests for reasonable accommodation are granted when the request is
made by a qualified individual with a disability.
If a qualified taxpayer believes that he or she has been discriminated against based on sex, race, color, national origin,
disability, reprisal or age, they can file a complaint with the Department of the Treasury – Internal Revenue Service. All
written complaints should be sent to:
Director, Civil Rights Division
Internal Revenue Service
1111 Constitution Avenue, NW, Rm. 2413
Washington, DC 20224
For all inquiries concerning taxpayer civil rights, contact us at the address referenced above, or e-mail us at
[email protected].

STOP HERE!
Thank you for completing this form.
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 (Rev. 10-2012)

3

Section B. For Certified Volunteer Preparer Completion
Remember: You are the link between the taxpayer’s information and a
correct tax return! Verify the taxpayer’s information on pages 1, 2 & 3 is
complete. All questions must be discussed with the taxpayer and all
“Unsure” responses should be changed to “Yes” or “No”.
Must be completed by Certified Volunteer only if persons are listed
in Part II Question 2
Check if persons are listed in Part II Question 2
Yes

No

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:

Section C. Certified Volunteer
Quality Reviewer Section
Review the tax return to ensure the
following actions have been taken.
1. The certification levels of this tax
return and volunteer preparer were
verified.
2. All unsure boxes were discussed
with the taxpayer and correctly
marked yes or no.
3. The information on pages one and
two was correctly addressed and
transferred to the return.
4. Taxpayer’s identity has been verified
and address and phone numbers are
correct.

Yes

No

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

5. Names, SSNs, ITINs, and EINs, were
verified and correctly transferred to the
return.
6. Filing status was verified and correct.

Yes

No

3. Did any of the persons listed in Part II, question 2 provide
more than 50% of their own support? If yes, which ones:

7. Personal and Dependency
Exemptions are entered correctly on
the return.
8. All Income (including income with or
without source documents) checked
“yes” in section A, part III was correctly
transferred to the tax return.

Yes

No
N/A

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

9. Adjustments to Income are correctly
reported.
10. Standard, Additional or Itemized
deductions are correct.
11. All credits are correctly reported.

Yes

No
N/A

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:

12. Withholding shown on Forms W-2,
1099 and Estimated Tax Payments
are correctly reported.
13. Direct Deposit/Debit and checking/
saving account numbers are correct.
14. The correct SIDN is shown on the
return.

Reminders
Use Publication 4012, Volunteer Resource Guide and Publication 17,
Your Federal Income Tax in making tax law determinations.

15. The taxpayer(s) was advised that they
are responsible for the information on
their return.

Additional Tax Preparer Notes:

Catalog Number 52121E

Form 13614-C (Rev. 10-2012)

4