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

Section A. To be completed by Taxpayer (continued)

Part III.

Income – In 2010, did you (or your spouse) receive:

(Check Yes, No or Unsure to all questions below)

Yes No Unsure

1. Wages or Salary? (Form(s) W-2)

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, 1099-OID)

5. Refund of state/local income taxes previously used as a deduction on 1040 Sch A? (Form(s)

1099-G)

6. Alimony Income?

7. Self-Employment Income/Loss (such as earnings from contract labor, small business)?

(Form(s) 1099-MISC)

8. Income (gain or loss) from the sale of Stocks, Bonds or Real Estate (including your home)?

(Form(s) 1099-B)

9. Disability Income (such as payments from SSA, VA, insurance, etc)? (Forms 1099-R, W-2)

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

11. Unemployment Compensation? (Form(s) 1099-G)

12. Social Security or Railroad Retirement Benefits? (Form(s) SSA-1099)

13. Income (profit or loss) from Rental Property?

14. Other Income: (gambling, lottery, prizes, awards, jury duty, etc.) Specify:

(Forms W-2 G, 1099-MISC)

Part IV. Expenses –

In 2010 Did you (or your spouse) pay:

(Check Yes, No or Unsure to all questions below)

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 paid for yourself, spouse or dependents? (such as tuition, books, fees, etc.)

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

5. Medical expenses?

6. Home mortgage interest?

7. Real estate taxes for your home or personal property taxes?

8. Charitable contributions?

9. Child/dependent care expenses that allowed you and your spouse, to work or to look for work?

Part V. Life Events

(

– In 2010 Did you (or your spouse):

Check Yes, No or Unsure to all questions below)

Yes No Unsure

1. Have a Health Savings Account? (Forms 5498-SA, 1099-SA)

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

3. Buy a home? If yes, closing date

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 previous years?

8. Pay any student loan interest?

9. Make estimated tax payments or apply last year’s refund to your 2010 tax?

If so how much?

10. If you are due a refund, would you like a direct deposit or split your refund?

11. If you are due a refund, would you like information on how to purchase U.S. Savings Bonds?

12. If you have a balance due, would you like information about all of your payment options? (such as

payment directly from your bank account, check, money order, credit/debit card or payment plan)

13614-C

Catalog Number 52121E

Form

(Rev. 10-2010)

Form 13614-C - Intake/interview & Quality Review Sheet - 2010 Page 2

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