13614-C Intake/Interview & Quality Review Sheet

Form 13614-C

Department of the Treasury - Internal Revenue Service

OMB Number
1545-1964

Intake/Interview & Quality Review Sheet

(October 2016)

You will need:
• Tax Information such as Forms W-2, 1099, 1098, 1095.
• Social security cards or ITIN letters for all persons on your tax return.
• Picture ID (such as valid driver's license) for you and your spouse.

• Please complete pages 1-3 of this form.
• You are responsible for the information on your return. Please provide
complete and accurate information.
• If you have questions, please ask the IRS-certified volunteer preparer.

Volunteers are trained to provide high quality service and uphold the highest ethical standards.
To report unethical behavior to the IRS, email us at [email protected]
Part I – Your Personal Information (If you are filing a joint return, enter your names in the same order as last year’s return)
1. Your first name
M.I.
Last name
Telephone number
2. Your spouse’s first name

M.I.

Last name

Telephone number

3. Mailing address
4. Your Date of Birth
7. Your spouse’s Date of Birth

Apt #
5. Your job title
8. Your spouse’s job title

10. Can anyone claim you or your spouse on their tax return?
11. Have you or your spouse:

Are you a U.S. citizen?
Yes
No
Is your spouse a U.S. citizen?
Yes
No
State
ZIP code

City

6. Last year, were you:
b. Totally and permanently disabled
9. Last year, was your spouse:
b. Totally and permanently disabled
Yes
No
Unsure
a. Been a victim of identity theft?

No

a. Full-time student
c. Legally blind
a. Full-time student
c. Legally blind

Yes
Yes
Yes
Yes

No
No
No
No

No

b. Adopted a child?

Yes

No

Yes

No

Yes
Yes

Part II – Marital Status and Household Information
Unmarried
Married

(This includes registered domestic partnerships, civil unions, or other formal relationships under state law)
Yes
No
a. If Yes, Did you get married in 2016?
Yes
No
b. Did you live with your spouse during any part of the last six months of 2016?
Date of final decree
Divorced
Legally Separated Date of separate maintenance agreement
Year of spouse’s death
Widowed

1. As of December 31, 2016, were
you:

2. List the names below of:
• everyone who lived with you last year (other than your spouse)
• anyone you supported but did not live with you last year
Name (first, last) Do not enter your
name or spouse’s name below

(a)

Catalog Number 52121E

Date of Birth
(mm/dd/yy)

(b)

Relationship
to you (for
example:
son,
daughter,
parent,
none, etc)
(c)

If additional space is needed check here

To be completed by a Certified Volunteer Preparer

Number of US
months
Citizen
lived in
(yes/no)
your home
last year

(d)

and list on page 3

(e)

Resident
of US,
Canada,
or Mexico
last year
(yes/no)

Single or
Married as
of 12/31/16
(S/M)

Full-time
Student
last year
(yes/no)

Totally and
Permanently
Disabled
(yes/no)

(f)

(g)

(h)

(i)

www.irs.gov

Is this
person a
qualifying
child/relative
of any other
person?
(yes/no)

Did this
person
provide
more than
50% of his/
her own
support?
(yes/no)

Did this
person
have less
than $4,050
of income?
(yes/no)

Did the
taxpayer(s)
provide more
than 50% of
support for
this person?
(yes/no/N/A)

Did the
taxpayer(s)
pay more than
half the cost of
maintaining a
home for this
person?
(yes/no)

Form 13614-C (Rev. 10-2016)

Page 2
Check appropriate box for each question in each section

Yes No Unsure Part III – Income – Last Year, Did You (or Your Spouse) Receive
1. (B) Wages or Salary? (Form W-2) If yes, how many jobs did you have last year?
2. (A) Tip Income?
3. (B) Scholarships? (Forms W-2, 1098-T)
4. (B) Interest/Dividends from: checking/savings accounts, bonds, CDs, brokerage? (Forms 1099-INT, 1099-DIV)
5. (B) Refund of state/local income taxes? (Form 1099-G)
6. (B) Alimony income or separate maintenance payments?
7. (A) Self-Employment income? (Form 1099-MISC, cash)
8. (A) Cash/check payments for any work performed not reported on Forms W-2 or 1099?
9. (A) Income (or loss) from the sale of Stocks, Bonds or Real Estate? (including your home) (Forms 1099-S,1099-B)
10. (B) Disability income? (such as payments from insurance, or workers compensation) (Forms 1099-R, W-2)
11. (A) Payments from Pensions, Annuities, and/or IRA? (Form 1099-R)
12. (B) Unemployment Compensation? (Form 1099G)
13. (B) Social Security or Railroad Retirement Benefits? (Forms SSA-1099, RRB-1099)
14. (M) Income (or loss) from Rental Property?
15. (B) Other income? (gambling, lottery, prizes, awards, jury duty, Sch K-1, royalties, foreign income, etc.) Specify
Yes No Unsure Part IV – Expenses – Last Year, Did You (or Your Spouse) Pay
1. (B) Alimony or separate maintenance payments? If yes, do you have the recipient’s SSN?
Yes
No
IRA (A)
401K (B)
Roth IRA (B)
2. Contributions to a retirement account?
3. (B) College or post secondary educational expenses for yourself, spouse or dependents? (Form 1098-T)
4. (B) Unreimbursed employee business expenses? (such as uniforms or mileage)
5. (B) Medical expenses? (including health insurance premiums)
6. (B) Home mortgage interest? (Form 1098)
7. (B) Real estate taxes for your home or personal property taxes for your vehicle? (Form 1098)
8. (B) Charitable contributions?
9. (B) Child or dependent care expenses such as daycare?
10. (B) For supplies used as an eligible educator such as a teacher, teacher’s aide, counselor, etc.?
11. (A) Expenses related to self-employment income or any other income you received?
12. (B) Student loan interest? (Form 1098-E)
Yes No Unsure Part V – Life Events – Last Year, Did You (or Your Spouse)
1. (HSA) Have a Health Savings Account? (Forms 5498-SA, 1099-SA, W-2 with code W in box 12)
2. (A) Have debt from a mortgage or credit card cancelled/forgiven by a commercial lender? (Forms 1099-C, 1099-A)
3. (A) Buy, sell or have a foreclosure of your home? (Form 1099-A)
4. (B) Have Earned Income Credit (EIC) disallowed in a prior year? If yes, for which tax year?
5. (A) Purchase and install energy-efficient home items? (such as windows, furnace, insulation, etc.)
6. (B) Live in an area that was affected by a natural disaster? If yes, where?
7. (A) Receive the First Time Homebuyers Credit in 2008?
8. (B) Make estimated tax payments or apply last year’s refund to this year’s tax? If so how much?
9. (A) File a federal return last year containing a “capital loss carryover” on Form 1040 Schedule D?
Catalog Number 52121E

www.irs.gov

Other

Form 13614-C (Rev. 10-2016)

Page 3

Check appropriate box for each question in each section
Yes No Unsure Part VI - Health Care Coverage - Last year, did you, your spouse, or dependent(s)
1. (B) Have health care coverage?
2. (B) Receive one or more of these forms? (Check the box)
Form 1095-B
Form 1095-C
3. (A) Have coverage through the Marketplace (Exchange)? [Provide Form 1095-A]
3a. (A) If yes, were advance credit payments made to help you pay your health care premiums?
3b. (A) If yes, Is everyone listed on your Form 1095-A being claimed on this tax return?
4. (B) Have an exemption granted by the Marketplace?
Visit http://www.healthcare.gov/ or call 1-800-318-2596 for more information on health insurance options and assistance.
If advance payments of the premium tax credit were paid on your behalf to help pay your health insurance premiums, you should report life changes, such
as, income, marital status or family size changes, to your Marketplace. Reporting changes will help to make sure you are getting the proper amount of
advance payments.
To be Completed by a Certified Volunteer Preparer (Use Publication 4012 and check the appropriate box(es) indicating Minimum Essential Coverage (MEC) for everyone listed on the return.)

Name (List dependents in the
same order as in Part II)
Taxpayer
Spouse
Dependent
Dependent
Dependent
Dependent

MEC
Entire Year

Part Year MEC
(mark months with coverage)

No MEC
J
J
J
J
J
J

F
F
F
F
F
F

M
M
M
M
M
M

A
A
A
A
A
A

M
M
M
M
M
M

J
J
J
J
J
J

J
J
J
J
J
J

A
A
A
A
A
A

S
S
S
S
S
S

O
O
O
O
O
O

N
N
N
N
N
N

D
D
D
D
D
D

Part VII – Additional Information and Questions Related to the Preparation of Your Return
1. Presidential Election Campaign Fund (If you check a box, your tax or refund will not change)
Check here if you, or your spouse if filing jointly, want $3 to go to this fund
You

Exemption
All Year

Exemption (mark months
exemptions applies)
J
J
J
J
J
J

F
F
F
F
F
F

M
M
M
M
M
M

A
A
A
A
A
A

M
M
M
M
M
M

J
J
J
J
J
J

J
J
J
J
J
J

A
A
A
A
A
A

S
S
S
S
S
S

O
O
O
O
O
O

N
N
N
N
N
N

Notes

D
D
D
D
D
D

Spouse

2. If you are due a refund, would you like:
a. Direct deposit
b. To purchase U.S. Savings Bonds
c. To split your refund between different accounts
Yes
No
Yes
No
Yes
No
3. If you have a balance due, would you like to make a payment directly from your bank account?
Yes
No
4. Provide an email address (optional) (this email address will not be used for contacts from the Internal Revenue Service)
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.
5. Other than English, what language is spoken in your home?
Prefer not to answer
6. Do you or any member of your household have a disability?
Yes
No
Prefer not to answer
7. Are you or your spouse a Veteran from the U.S. Armed Forces?
Yes
No
Prefer not to answer
Additional comments

Catalog Number 52121E

www.irs.gov

Form 13614-C (Rev. 10-2016)

Page 4

Part VIII – IRS-Certified Volunteer Quality Reviewer Section
Review the tax return with the taxpayer to ensure:
• Taxpayer (and Spouse's) identity was verified with a photo ID.
• The volunteer return preparer/quality reviewer are certified to prepare/review this return and return is within scope of the program.
• All questions in Parts I through VI have been answered.
• All unsure boxes were discussed with the taxpayer and correctly marked yes or no.
• The information on pages one through three was correctly addressed and entered on the return.
• Names, SSNs, ITINs, and EINs, were verified and correctly transferred to the return.
• Filing status was verified and correct.
• Personal and Dependency Exemptions are entered correctly on the return.
• All Income (including income with or without source documents) checked "yes" in Part III was correctly transferred to the tax return.
• Adjustments to income, such as student loan interest, IRA contributions, self employment tax, were verified and are correct.
• Standard, Additional or Itemized Deductions are correct.
• All credits are correctly reported.
• All applicable provisions of ACA were considered for each person named on the tax return and were entered correctly.
• Any Shared Responsibility Payments are correct.
• Withholding shown on Forms W-2, 1099 and Estimated Tax Payments are correctly reported.
• Direct Deposit/Debit and checking/saving account numbers are correct.
• SIDN is correct on the return.
• The taxpayer(s) was advised that they are responsible for the information on their return.
Certified Volunteer Preparer’s name/initials (optional)

Certified Volunteer Quality Reviewer’s name/initials (optional)

Additional Tax Preparer notes

Privacy Act and Paperwork Reduction Act Notice
The Privacy Act of 1974 requires that when we ask for information we tell you our legal right to ask for the information, why we are asking for it, and how it will be used. We must also tell you what could happen if we do
not receive it, and whether your response is voluntary, required to obtain a benefit, or mandatory.
Our legal right to ask for information is 5 U.S.C. 301. We are asking for this information to assist us in contacting you relative to your interest and/or participation in the IRS volunteer income tax preparation and outreach
programs. The information you provide may be furnished to others who coordinate activities and staffing at volunteer return preparation sites or outreach activities. The information may also be used to establish effective
controls, send correspondence and recognize volunteers. Your response is voluntary. However, if you do not provide the requested information, the IRS may not be able to use your assistance in these programs.
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

www.irs.gov

Form 13614-C (Rev. 10-2016)