Form 13614-C - Intake/interview And Quality Review Sheet
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1
2Department of the Treasury – Internal Revenue Service
13614-C
Form
OMB # 1545-1964
Intake/Interview & Quality Review Sheet
(Rev. 10-2012)
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
No
Apt#
City
State
Zip Code
3. Mailing Address
4. Contact Information
Phone:
Cell Phone:
E-mail:
5. Your Date of Birth
6. Your Job Title
Are you:
7. Legally Blind
Yes
No
8. Totally and Permanently Disabled
Yes
No
9. Your Spouse’s Date of Birth
10. Your Spouse’s Job Title
Is Your Spouse: 11. Legally Blind
Yes
No
12. Totally and Permanently Disabled
Yes
No
13. Can anyone claim you or your spouse on their tax return?
Yes
No
Unsure
Part II. Marital Status and Household Information
1. As of December 31, 2012, were you?
Single
Married: Did you live with your spouse during any part of the last six months of 2012?
Yes
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)
Date of Birth
Relationship to you
Number
US Citizen or
Marital
Full-
Received
Do not enter your name or
(mm/dd/yy)
(e.g. daughter,
of months
resident of US,
Status
time
less than
spouse’s name below.
(b)
son, mother, sister,
lived in
Canada or
as of
Student
$3800
none)
your home
Mexico in 2012
12/31/12
in 2012
income in
(a)
in 2012
(yes/no)
(S/M)
(yes/no)
2012
(c)
(d)
(e)
(f)
(g)
(yes/no)
(h)
To check the status of your REFUND visit “Where’s My Refund?” on
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
wi.voltax@irs.gov
or call toll free 1-877-330-1205.
Catalog Number 52121E
13614-C
1
Form
(Rev. 10-2012)
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