Form 13614 - Volunteer Return Preparation Program Hurricanes Katrina, Rita And Wilma Intake/interview Sheet

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Department of the Treasury – Internal Revenue Service
13614K
Form
Volunteer Return Preparation Program Hurricanes
OMB # 1545-1999
(February 2006)
Katrina, Rita and Wilma Intake/Interview Sheet
Part I
All Taxpayers Assisted
Instructions: This section will capture data to properly determine if an individual qualifies for any Hurricane Katrina, Rita
or Wilma tax benefits. It should be used by screeners, preparers, or others involved in the Volunteer Return Preparation
Program (VRPP) for all taxpayers assisted. Use with Form 13614, Interview and Intake Sheet.
1. HOUSING DISPLACED INDIVIDUALS
N/A
COMMENTS
YES
NO
Did you house a Katrina displaced individual in your home in 2005?
1A
If yes, enter number of days in comments.
1B
Was the displaced individual your dependent or spouse?
2. GIFTS TO CHARITY
Did you make any cash charitable contributions between August
2A
28, 2005 and December 31, 2005?
2B
Do you have Katrina related charitable mileage?
2C
If yes, do you have written records?
3. HOPE AND LIFETIME LEARNING CREDIT
Were you, your spouse, or your dependent enrolled and paying
tuition at an eligible educational institution located in the Gulf
3A
Opportunity Zone?
4. HURRICANE KATRINA, RITA, OR WILMA IMPACTED
Hurricanes Katrina, Rita or Wilma
Were you impacted by
?
4A
(If yes, complete Part II of this form. If no, the form is complete.)
Part II
Hurricanes Katrina, Rita, and Wilma Impacted Individuals Only
Instructions: This section is designed to capture critical data to properly prepare tax returns for Hurricane Katrina, Rita,
or Wilma impacted individuals only. It should be used by screeners, preparers, or others involved in the return
preparation process to quickly determine if a volunteer can assist the taxpayer or needs to refer them to a Taxpayer
Assistance Center (TAC), paid professional preparer, or other organizations, if available, trained to prepare casualty loss
tax returns. If the taxpayer is referred for assistance, Form 13614K should be returned to the taxpayer.
1. CORE DISASTER AREA
1A
What State?
1B
What County/Parish?
2. RECORDS/INCOME
YES
NO
N/A
COMMENTS
2A
Do you have a copy of your 2004 Federal Income Tax Return?
2B
Do you have your 2005 income and expenses? i.e., W-2, 1099, 1098
(If no to Q, 2A or 2B, see Tax Record Reconstruction on reverse.)
3. EARNED INCOME CREDIT AND ADDITIONAL CHILD TAX CREDIT
Was your 2004 earned income greater than your 2005 earned
3A
income?
4. RETIREMENT PLAN WITHDRAWALS
Did you receive a distribution from a qualified retirement plan,
4A
tax sheltered annuity or IRA in 2005?
5. PROPERTY
5A
Did you experience a loss of personal or real property?
5B
Did you receive any reimbursements?
Was the reimbursement greater than the property value?
(If yes, the VRPP site may be able to prepare the tax return.)
5C
(If no, give the taxpayer this intake sheet and refer them to the
Casualty Loss Information on reverse.)
13614K
Form
(2-2006)
Catalog Number 47919C

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