Form 13614-C - Intake/interview & Quality Review Sheet - 2010

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Department of the Treasury – Internal Revenue Service
13614-C
Form
Intake/Interview & Quality Review Sheet
OMB # 1545-1964
(Rev. 1 -2010)
0
Section A. Page 1 and Page 2 to be completed by Taxpayer
Thank you for allowing us to prepare your tax return. It is very important for you to provide the information on this form
to help our certified volunteer preparer in completing your return. If you have any questions, please ask.
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.
Proof of Identity (such as drivers license or other picture ID).
Part I. Your Personal Information
1. Your First Name
M. I.
Last Name
Are you a U.S. Citizen?
Yes
No
2. Spouse’s First Name
M. I.
Last Name
Is spouse a U.S. Citizen?
Yes
No
Apt#
City
State
Zip Code
3. Mailing Address
4. Phone
E-mail
Primary:
Other:
5. Your Date of Birth
6. Your Occupation
7. Are you Legally Blind
Yes
No
8. Totally and Permanently Disabled
Yes
No
9. Spouse’s Date of Birth
10. Spouse’s Occupation
11. Is Spouse Legally Blind
Yes
No
12. Totally and Permanently Disabled
Yes
No
13. Can your parents or someone else claim you or your spouse on their tax return?
Yes
No
Unsure
14. Other than English what language is spoken in your home?
15. Are you or a member of your household considered disabled?
Yes
No
Part II. Family and Dependent Information
1. As of December 31, 2010, your marital status was:
Single
Married: Did you live with your spouse during any part of the last six months of 2010?
Yes
No
Divorced or Legally Separated: Date of final decree or separate maintenance agreement:
Widowed: Year of spouse’s death:
2. List the name of everyone below who lived in your home and outside your home that you supported during 2010.
If additional space is needed please check here and use page 4 for additional information.
Name (first, last)
Date of Birth
Relationship to you
Number
US Citizen or
Single
Full-
Received
Do not enter your name or
(mm/dd/yy)
(e.g. son, mother,
of months
resident of the
as of
time
more than
Spouse’s name below.
sister)
lived in
US, Canada
12/31/10
student
$3650 in
your
or Mexico
(yes/no)
(yes/no)
income
home
(yes/no)
(yes/no)
(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
Volunteers assisting with preparing your return are trained to provide high quality service and
uphold the highest ethical standards.
To report any concerns to IRS on site operating issues please call Toll Free 1-877-330-1205
or email us at WI.Voltax@irs.gov.
13614-C
Form
(Rev. 10-2010)
Catalog Number 52121E
1

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