Fillable Printable Form 13614-C

Form 13614-C

Catalog Number 52121E www.irs.gov

Form

13614-C (Rev. 10-2017)

Form 13614-C

(October 2017)

Department of the Treasury - Internal Revenue Service

Intake/Interview & Quality Review Sheet

OMB Number

1545-1964

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.

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

Are you a U.S. citizen?

Yes No

2. Your spouse’s first name M.I. Last name Telephone number

Is your spouse a U.S. citizen?

Yes No

3. Mailing address Apt # City State ZIP code

4. Your Date of Birth 5. Your job title

6. Last year, were you: a. Full-time student Yes No

b. Totally and permanently disabled

Yes No

c. Legally blind Yes No

7. Your spouse’s Date of Birth 8. Your spouse’s job title

9. Last year, was your spouse: a. Full-time student Yes No

b. Totally and permanently disabled Yes No c. Legally blind Yes No

10. Can anyone claim you or your spouse as a dependent?

Yes No Unsure

11. Have you or your spouse: a. Been a victim of identity theft?

Yes No b. Adopted a child?

Yes

Part II – Marital Status and Household Information

1. As of December 31, 2017, were

you:

Never Married (This includes registered domestic partnerships, civil unions, or other formal relationships under state law)

Married

a. If Yes, Did you get married in 2017?

Yes No

b. Did you live with your spouse during any part of the last six months of 2017?

Yes No

Divorced

Date of final decree

Legally Separated

Date of separate maintenance agreement

Widowed

Year of spouse’s death

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

To be completed by a Certified Volunteer Preparer

Name (first, last) Do not enter your

name or spouse’s name below

(a)

Date of Birth

(mm/dd/yy)

(b)

Relationship

to you (for

example:

son,

daughter,

parent,

none, etc)

(c)

Number of

months

lived in

your home

last year

(d)

Citizen

(yes/no)

(e)

Resident

of US,

Canada,

or Mexico

last year

(yes/no)

(f)

Single or

Married as

of 12/31/17

(S/M)

(g)

Full-time

Student

last year

(yes/no)

(h)

Totally and

Permanently

Disabled

(yes/no)

(i)

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)

If additional space is needed check here and list on page 3

• 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.

Page 2

Catalog Number 52121E www.irs.gov

Form

13614-C (Rev. 10-2017)

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

2. Contributions to a retirement account?

IRA (A) Roth IRA (B) 401K (B) Other

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) or other credits 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?

Page 3

Catalog Number 52121E www.irs.gov

Form

13614-C (Rev. 10-2017)

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?

Form 1095-B Form 1095-C2. (B) Receive one or more of these forms? (Check the box)

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)

MEC

Entire Year

No MEC

Part Year MEC

(mark months with coverage)

Exemption (mark months

exemptions applies)

Exemption

All Year

Notes

Taxpayer