Fillable Form 13614-C - Intake/interview And Quality Review Sheet (Page 2 of 2) in pdf

Section A. Please complete – check Yes, No or Unsure to all questions below. Please ask if you need help.

Part III.

Income – In 2012, did you (or your spouse) receive:

Yes No

Unsure

1. Wages or Salary? (Form W-2) If yes, how many jobs did you have in 2012?

2. Tip Income?

3. Scholarships? (Forms W-2, 1098-T)

4. Interest/Dividends from: checking/savings accounts, bonds, CDs, brokerage? (Forms 1099-INT, 1099-DIV)

5. Refund of state/local income taxes? (Form 1099-G)

6. Alimony Income?

7. Self-Employment Income? (Form 1099-MISC)

8. Cash/check payments for any work performed not reported on Forms W-2 or 1099?

9. Income (or loss) from the sale of Stocks, Bonds or Real Estate (including your home)? (Forms 1099-S, 1099-B)

10. Disability Income (such as payments from insurance, or workers compensation)? (Forms 1099-R, W-2)

11. Distributions from Pensions, Annuities, and/or IRA? (Form 1099-R)

12. Unemployment Compensation? (Form 1099-G)

13. Social Security or Railroad Retirement Benefits? (Forms SSA-1099, RRB-1099)

14. Income (or loss) from Rental Property?

15. Other Income: (gambling, lottery, prizes, awards, jury duty, etc.)? (Forms W-2 G, 1099-MISC)

Specify:

Part IV. Expenses –

In 2012 Did you (or your spouse) pay:

Yes No

Unsure

1. Alimony: If yes, do you have the recipient’s SSN?

Yes

2. Contributions to a retirement account?

IRA

Roth IRA

401K

Other

3. Educational expenses for yourself, spouse or dependents, such as tuitions, books, fees, etc.? (Form 1098-T)

4. Unreimbursed employee business expenses (such as uniforms or mileage)?

5. Medical expenses (including health insurance premiums)?

6. Home mortgage interest? (Form 1098)

7. Real estate taxes for your home or personal property taxes for your vehicle? (Form 1098)

8. Charitable contributions?

9. Child or dependent care expenses such as day-care?

10. For supplies used as an eligible educator such as a teacher, teacher’s aide, counselor, etc.?

Part V. Life Events

– In 2012 Did you (or your spouse):

Yes No

Unsure

1. Have a Health Savings Account? (Forms 5498-SA, 1099-SA, W-2 with code W in Box 12)

2. Have debt from a mortgage or credit card canceled/forgiven by a commercial lender? (Forms 1099-C, 1099A)

3. Buy, sell or have a foreclosure of your home? (Form 1099-A)

4. Have Earned Income Credit (EIC) disallowed in a prior year? If yes, for which tax year?

5. Purchase and install energy-efficient home items? (such as windows, furnace, insulation, etc.)

6. Live in an area that was affected by a natural disaster? If yes, where?

7. Receive the First Time Homebuyers Credit in 2008?

8. Pay any student loan interest? (Form 1098-E)

9. Make estimated tax payments or apply last year’s refund to your 2012 tax? If so how much?

10. Attend school as a full time student? (Form 1098-T)

11. Adopt a child?

12. File a 2011 federal tax return containing a “capital loss carryover” on Form 1040 Schedule D?

13. Become a victim of identity theft?

Presidential Election Campaign Fund: (If you check a box, your tax or refund will not change.)

You

Spouse

Check here if you, or your spouse if filing jointly, want $3 to go to this fund

Catalog Number 52121E

13614-C

Form

(Rev. 10-2012)

Form 13614-C - Intake/interview And Quality Review Sheet Page 2

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