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

Additional Information and Questions related to the preparation of your return

Many free tax preparation sites operate by receiving grant money. The data from the following questions

may be used by this site to apply for these grants. Your answers will be used only for statistical purposes.

Other than English what language is spoken in the home?

Are you or a member of your household considered disabled?

Yes

If you are due a refund or have a balance due:

•

Ask your preparer about Direct Deposit. It is the fastest, safest way to receive your tax refund. When you combine e-file

and direct deposit, the IRS will likely issue your refund in as few as 10 days.

•

Ask your preparer about purchasing Series I U.S. Savings Bonds with part or all of your tax refund. Savings bonds

are a safe and secure way to invest in the future. Purchase I Bonds for yourself or others in multiples of $50 and

earn interest for up to 30 years.

If you are due a refund, would you like a direct deposit?

Yes

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

Yes

If you are due a refund, would you like information on how to split your refund between accounts?

Yes

If you have a balance due, would you like to make a payment directly from your bank account?

Yes

Additional comments:

Under no circumstances will the Internal Revenue Service tolerate discriminatory treatment of taxpayers by its employees,

or individuals who volunteer or work at Volunteer Income Tax Assistance (VITA) and Tax Counseling for the Elderly

(TCE) sites. No taxpayer shall be subject to discrimination on the basis of sex, race, color, national origin, reprisal, disability

or age in educational programs or activities supported by the Department of the Treasury – Internal Revenue Service.

Taxpayers with a disability may require a reasonable accommodation in order to participate or receive the benefits of a

program or activity supported by the Department of the Treasury – Internal Revenue Service. Site Coordinators and

Managers are responsible for ensuring that requests for reasonable accommodation are granted when the request is

made by a qualified individual with a disability.

If a qualified taxpayer believes that he or she has been discriminated against based on sex, race, color, national origin,

disability, reprisal or age, they can file a complaint with the Department of the Treasury – Internal Revenue Service. All

written complaints should be sent to:

Director, Civil Rights Division

Internal Revenue Service

1111 Constitution Avenue, NW, Rm. 2413

Washington, DC 20224

For all inquiries concerning taxpayer civil rights, contact us at the address referenced above, or e-mail us at

eeo.external.civil.rights@irs.gov.

STOP HERE!

Thank you for completing this form.

Paperwork Reduction Act Notice

The Paperwork Reduction Act requires that the IRS display an OMB control number on all public information requests. The OMB Control Number for

this study is 1545-1964. Also, if you have any comments regarding the time estimates associated with this study or suggestion on making this process

simpler, please write to the Internal Revenue Service, Tax Products Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW,

Washington, DC 20224

13614-C

Catalog Number 52121E

Form

(Rev. 10-2012)

Form 13614-C - Intake/interview & Quality Review Sheet - 2012 Page 3

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