Free Form 13614-C (9-2008) - Federal

Form 13614-C (September 2008)

Department of the Treasury ­ Internal Revenue Service

Intake/Interview & Quality Review Sheet
· · · ·
Last Name 5. Totally and Permanently Disabled No Last Name Yes No

OMB # 1545-1964

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 2. Date of Birth
(mm/dd/yyyy)

Part I: Taxpayer Information
1. Your First Name 3. US Citizen or Resident Alien Yes No 7. Spouse's First Name 9. US Citizen or Resident Alien Yes 13. Address 14. Phone Number and e-mail address Phone: ( e-mail: 16. On December 31 st Single a. Were you: Legally Married ) No M.I.

4. Legally Blind Yes M.I.

6. Occupation 8. Date of Birth
(mm/dd/yyyy)

10. Legally Blind Yes No

11. Totally and Permanently Disabled 12. Occupation Yes No State Zip Code 15. Could you or your spouse be claimed as a dependent on the income tax return of any other person? Yes No

Apt # City

Separated

Divorced

Widowed No

b. If married, did you live with your spouse during any part of the last six months of the year? c. Is your spouse deceased? If yes, provide the date of death.

Yes (mm/dd/yyyy)

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 (d) US Citizen, Resident of US, Canada or Mexico (yes or no) (e) Is the dependent a full time student? (yes or no) (f)

(a)

(b)

(c)

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 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No 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 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 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 Yes Yes Yes Yes Yes No No No No No 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? Single MFJ MFS* HOH QW

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

*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?
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Catalog Number 52121E

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

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Form 13614-C (9-2008)

Quality Review
· 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.
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.

Verifying the Return 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No

Check each item only when you verify that the review step is complete. A completed Intake/Interview Sheet was used to prepare this tax return. Name(s) and SSNs/ITINs for taxpayer(s) match the supporting documents. The taxpayer(s) address and Date of Birth match the Intake/Interview Sheet and have been confirmed with the taxpayer. Filing status was correctly determined and is notated on the Intake/Interview Sheet. Dependent information is correctly shown including names, SSNs/ITINs, and DOBs. All income indicated on the Intake/Interview Sheet and W-2s/1099s is shown. Any Adjustments to Income are correctly reported. 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. The non-refundable credits have been correctly reported. All payments from W-2s and F1099's and estimated tax payments are correct. The refundable credits are correctly reported including the EIC determination based on the information provided. If direct deposit or debit was elected, information on the return matches the taxpayer's checking/saving account and routing information.

Yes Yes Yes Yes

No No No No

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
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Form 13614-C (9-2008)