Form 13614-C Intake/Interview & Quality Review Sheet

Form 13614-C

Department of the Treasury - Internal Revenue Service

OMB Number
1545-1964

Intake/Interview and Quality Review Sheet

(November 2024)

• Complete pages 1-6 of this form.
D You will need:
• Tax Information such as Forms W-2, 1099, 1098, 1095.
• You are responsible for the information on your return. Provide complete and accurate
R • Social Security cards or ITIN letters for all persons on your tax return
information.
• Picture ID (such as valid driver's license) for you and your spouse
• If you have questions, ask the IRS-certified volunteer preparer.
A
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]
F Your first name (pronouns, optional)
M.I.
Last name
Your date of birth
Your job title
T

Spouse's first name (pronouns, optional) M.I.

Last name

Spouse’s date of birth Spouse’s job title

C Mailing address
O Your telephone number
Spouse's telephone number
P
Check if you or your spouse were in 2024:
Y A U.S. citizen
You
Spouse
In the U.S. on a visa
A full-time student

You
You

Apt #

City

State

ZIP code

Did you live or work in two or more states in 2024
Yes
No
Legally blind
You
Spouse
No
Totally and permanently disabled
You
Spouse
No
Issued an identity protection PIN (IPPIN)
You
Spouse
No
Owners or holders of any digital assets
You
Spouse
No

Spouse
Spouse

No
No
No

If you have a balance due, how would you like to make your payment
Bank account
IRS.gov Direct Pay
Set up installment agreement
Mail payment to IRS

Would you like to receive written communications from the IRS in a language other than English
What language

You

Spouse

No

Would you like information on how to vote and/or how to register to vote
Would you, or your spouse if married filing jointly, like $3 to go to the Presidential Election Campaign Fund
As of December 31, 2024, what was your marital status
If married, were you married for all of 2024
Never Married
Married
Did you live with your spouse during any part of the last six months of 2024
Divorced
Legally Separated but not Divorced
Date of final decree
Date of separate maintenance decree

Yes
You

No
Spouse

No

Yes
No
Yes
No
Widowed
Year of spouse’s death

To be completed by certified volunteer: Can anyone else claim the taxpayer or spouse on their tax return
List the names below of everyone who lived with you last year (except your
spouse) AND anyone you supported but did not live with you last year.

Catalog Number 52121E

Date of birth
(mm/dd/yy)

Relationship to you Number of
(child, parent, none, months lived in
etc.)
your home in
2024

F
O
R

Email address (optional)

If due a refund, how would you like your refund
Direct deposit
Check by mail
Split refund between accounts
Other

Name (first, last)

N
O
T

Single or Married
as of 12/31/2024
(S/M)

Yes

Answer Yes or No (Y/N)
U.S.
Citizen

Resident of
U.S., Canada
or Mexico

www.irs.gov

Full-time
student

Totally and
permanently
disabled

No

To be completed by certified volunteer
(Yes, No, or N/A)
Issued
IPPIN

Qualifying
child or
relative of
any other
person

This person
provided
more than
50% of their
own support

This
person had
less than
$5,050 of
income

Taxpayer(s)
provided
more than
50% of
support for
this person

Taxpayer(s)
paid more than
half the cost of
maintaining a
home for this
person

Form 13614-C (Rev. 11-2024)

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Income: Answer the following questions on the left side of this page. Check only the boxes that apply to you and/or your spouse.

D Received money from any of the following in 2024:
R (B) Wages as a part-time or full-time employee
A How many jobs
F (B/A) Tips
T (B/A) Retirement account, pension or annuity proceeds
C
O
P
Y

(To be completed by certified volunteer) Income to be included Notes/Comments
(B) W-2s

#

(B/A) Tips (Basic when reported on W2)
(B/A) 1099-R (Basic when taxable amount is reported) #
(A) Qualified Charitable Distribution From 1099-R

$

(B) Disability benefits (such as payments from insurance and
worker's compensation)

(B) Disability benefits on 1099-R or W-2

#

(B) Social Security or Railroad Retirement Benefits

(B) SSA-1099, RRB-1099

#

(B) Unemployment benefits

(B) 1099-G

#

(B) Refund of state or local income tax

(B) Refund

$

(B) Itemized last year
#

Yes

(B) Interest or dividends (bank account, bonds, etc.)

(B) 1099-INT

(A) Sale of stocks, bonds or real estate

(A) 1099-B (include brokerage statement)

Did you report a loss on last year’s return

Yes

No

(B) Alimony

(B) 1099-DIV

Capital loss carryover

(A/M) Income from renting out your house or a room in your house
If yes, did you use the dwelling unit as a personal residence and
rent it for fewer than 15 days
Yes
No

F
O
R
R
E
L
E
A
S
E

No
#
#

Yes

(B) Alimony
Excluded from income

No
$

Yes

No

(A/M) Rental income (Advanced when the dwelling is a personal
residence and rented for fewer than 15 days)
Rental expense

$

Income from renting personal property such as a vehicle
(B) Gambling winnings, including lottery

(B) W-2G or other gambling winnings (list losses below if
taxpayer can itemize deductions)
#

(A) Payments for contract or self-employment work

(A) Schedule C

Did you report a loss on last year's return

Yes

No

1099-MISC

#

1099-NEC

#

1099-K

#

Other income reported elsewhere
Schedule C expenses
Any other money received during the year? (example: cash
payments, jury duty, awards, digital assets, royalties, union strike
benefits)
Catalog Number 52121E

N
O
T

$

Other income (see Pub 4012 for guidance on other income, i.e.,
scope of service chart)
www.irs.gov

Form 13614-C (Rev. 11-2024)

Page 3

Expenses and Tax Related Events: Answer the questions on the left side of this page. Check only the boxes that apply to you and/or your spouse.

D Paid any of the following expenses to itemize in 2024?
R
(A) Mortgage Interest
A (A) Taxes: state, local, real estate, sales, etc.
F (A) Medical, dental, prescription expenses
T (A) Charitable contributions
Paid any of these expenses in 2024?

C
O
P
Y

Notes/Comments

(To be completed by certified volunteer) Standard
or Itemized Deductions
(A) 1098

(B) Standard deduction

#

(A) Itemized deduction

(To be completed by certified volunteer) Expenses to report

(B) Student loan interest

(B) 1098-E

(B) Child and dependent care

(B) Child and dependent care credit

(B/A) Contributions to a retirement account

(B/A) IRA (Basic if a Roth IRA or 401K)

(B) School supplies by a teacher, teacher’s aide or other educator

(B) Educator expenses deduction

$

(B) Alimony payments (do not include child support)

(B) Alimony payments with spouse’s SSN

$

Adjustment to income
Did any of the following happen during 2024?
(B) You or someone in your family took educational classes
(technical school, college, job related, etc.)

Yes

Notes/Comments

No

(To be completed by certified volunteer) Information to report

Notes/Comments

(B) Taxable scholarship income
(B) 1098-T (itemized statement from school, invoice, etc.)
(B) Education credit or tuition and fees deduction

(A) Sell a home

(A) Sale of home (1099-S)

(A) Have a health savings account (HSA)

HSA contributions

(A) Purchase health insurance through the Marketplace (Exchange)

(A) 1095-A

(A) Purchase and install energy-efficient home items (example:
windows, furnace, insulation, etc.)

(B) Energy efficient home improvement credit

(A) Have credit card, mortgage, or other debt cancelled/forgiven
by a lender

(A) 1099-C

(A) Have a loss related to a declared Federal disaster area

(A) 1099-A

HSA distributions

Disaster relief impacts return
(B) Have a tax credit disallowed (example: earned income credit,
child tax credit, or American opportunity credit)

(B) EITC, CTC, AOTC or HOH disallowed in a previous year
Year disallowed
Reason

Receive any letter or bill from the IRS

Eligible for Low Income Taxpayer Clinic referral

(B) Make estimated tax payments or apply last year’s refund to
2024 taxes

Estimated tax payments
Last year’s refund applied to this year
Last year’s return available

Catalog Number 52121E

www.irs.gov

Form 13614-C (Rev. 11-2024)

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Optional Information

D The following information is for statistical purposes only. Your responses to these questions are not a part of your tax return and are not transmitted to the
R IRS with your tax return. You are not required to answer these questions.
Very well
Well
Not well
Not at all
Prefer not to answer
A 1. Would you say you can carry on a conversation in English
Very well
Well
Not well
Not at all
Prefer not to answer
F 2. Would you say you can read a newspaper in English
3. Do you or any member of your household have a disability
Yes
No
Prefer not to answer
T
4. Are you or your spouse a Veteran of the U.S. Armed Forces

C
O
P
Y

Yes

5. What is your race and/or ethnicity? (select all that apply)

No

Prefer not to answer

6. What is your spouse’s race and/or ethnicity? (select all that apply)

Prefer not to answer

Prefer not to answer

American Indian or Alaska Native (for example, Navajo Nation, Blackfeet Tribe
of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat
Traditional Government, Nome Eskimo Community, Aztec, Maya, etc.)

American Indian or Alaska Native (for example, Navajo Nation, Blackfeet Tribe
of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat
Traditional Government, Nome Eskimo Community, Aztec, Maya, etc.)

Asian (for example, Chinese, Asian Indian, Filipino, Vietnamese, Korean,
Japanese, etc.)

Asian (for example, Chinese, Asian Indian, Filipino, Vietnamese, Korean,
Japanese, etc.)

Black or African American (for example, African American, Jamaican, Haitian,
Nigerian, Ethiopian, Somali, etc.)

Black or African American (for example, African American, Jamaican, Haitian,
Nigerian, Ethiopian, Somali, etc.)

Hispanic or Latino (for example, Mexican, Puerto Rican, Salvadoran, Cuban,
Dominican, Guatemalan, etc.)

Hispanic or Latino (for example, Mexican, Puerto Rican, Salvadoran, Cuban,
Dominican, Guatemalan, etc.)

Middle Eastern or North African (for example, Lebanese, Iranian, Egyptian,
Syrian, Iraqi, Israeli, etc.)

Middle Eastern or North African (for example, Lebanese, Iranian, Egyptian,
Syrian, Iraqi, Israeli, etc.)

Native Hawaiian or Pacific Islander (for example, Native Hawaiian, Samoan,
Chamorro, Tongan, Fijian, Marshallese, etc.)

Native Hawaiian or Pacific Islander (for example, Native Hawaiian, Samoan,
Chamorro, Tongan, Fijian, Marshallese, etc.)

White (for example, English, German, Irish, Italian, Polish, Scottish, etc.)

White (for example, English, German, Irish, Italian, Polish, Scottish, etc.)

Privacy Act and Paperwork Reduction Act Notice
We are asking for this information so you may participate in the IRS Volunteer Income Tax Assistance (VITA) and Tax Counseling for the Elderly (TCE) program which
provides IRS-certified volunteer income tax preparers to assist with basic income tax return preparation for qualified individuals. The IRS authority to collect this
information is 5 U.S.C. section 301 and 26 U.S.C. section 7801. The information you provide may be disclosed to others who coordinate VITA/TCE staffing, outreach, and
other VITA/TCE related activities. The IRS may only disclose your return and return information as provided by 26 U.S.C. section 6103. All other records may be disclosed
only for purposes the IRS deems are compatible with the purpose for which IRS collected the records, and consistent with any routine use disclosures described in the
System of Record Notice (SORN) Treasury/IRS 24.030, Customer Account Data Engine (CADE) Individual Master File (IMF). You may view Treasury/IRS SORNs on the
Treasury SORN website at Treasury.gov/System of Records Notices (SORNs). Providing this information is voluntary however, if you do not provide the requested
information the IRS volunteers may not be able to assist you with preparing and filing your tax return.
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:TS:CAR:MP:T:T:SP, 1111 Constitution Ave. NW, Washington, DC 20224.
Catalog Number 52121E

www.irs.gov

Form 13614-C (Rev. 11-2024)

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Additional Notes/Comments

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Catalog Number 52121E

www.irs.gov

Form 13614-C (Rev. 11-2024)