Fillable Form 13614-C: Intake/Interview & Quality Review Sheet (United Way of Southeast Louisiana)

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Form 13614-C: Intake/Interview & Quality Review Sheet (United Way of Southeast Louisiana)

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Catalog Number 52121E www.irs.gov
Form
13614-C (Rev. 10-2020)
Form 13614-C
(October 2020)
Department of the Treasury - Internal Revenue Service
Intake/Interview & Quality Review Sheet
OMB Number
1545-1964
You will need:
• Tax Information such as Forms W-2, 1099, 1098, 1095.
• Social security cards or ITIN letters for all persons on your tax return.
• Picture ID (such as valid driver's license) for you and your spouse.
Volunteers are trained to provide high quality service and uphold the highest ethical standards.
To report unethical behavior to the IRS, email us at wi.voltax@irs.gov
Part I – Your Personal Information (If you are filing a joint return, enter your names in the same order as last year’s return)
1. Your first name M.I. Last name Daytime telephone number
Are you a U.S. citizen?
Yes No
2. Your spouse’s first name M.I. Last name Daytime telephone number
Is your spouse a U.S. citizen?
Yes No
3. Mailing address Apt # City State ZIP code
4. Your Date of Birth 5. Your job title
6. Last year, were you: a. Full-time student Yes No
b. Totally and permanently disabled
Yes No
c. Legally blind Yes No
7. Your spouse’s Date of Birth 8. Your spouse’s job title
9. Last year, was your spouse: a. Full-time student Yes No
b. Totally and permanently disabled Yes No c. Legally blind Yes No
10. Can anyone claim you or your spouse as a dependent?
Yes No Unsure
11. Have you, your spouse, or dependents been a victim of tax related identity theft or been issued an Identity Protection PIN?
Yes No
Part II – Marital Status and Household Information
1. As of December 31, 2020, what
was your marital status?
Never Married (This includes registered domestic partnerships, civil unions, or other formal relationships under state law)
Married
Yes No
b. Did you live with your spouse during any part of the last six months of 2020?
Yes No
a. If Yes, Did you get married in 2020?
Divorced
Date of final decree
Legally Separated
Date of separate maintenance decree
Widowed
Year of spouse’s death
2. List the names below of:
• everyone who lived with you last year (other than your spouse)
• anyone you supported but did not live with you last year
To be completed by a Certified Volunteer Preparer
If additional space is needed check here and list on page 3
• Please complete pages 1-4 of this form.
• You are responsible for the information on your return. Please provide
complete and accurate information.
• If you have questions, please ask the IRS-certified volunteer preparer.
Name (first, last) Do not enter your
name or spouse’s name below
(a)
Date of Birth
(mm/dd/yy)
(b)
Relationship
to you (for
example:
son,
daughter,
parent,
none, etc)
(c)
Number of
months
lived in
your home
last year
(d)
US
Citizen
(yes/no)
(e)
Resident
of US,
Canada,
or Mexico
last year
(yes/no)
(f)
Single or
Married as
of 12/31/20
(S/M)
(g)
Full-time
Student
last year
(yes/no)
(h)
Totally and
Permanently
Disabled
(yes/no)
(i)
Is this
person a
qualifying
child/relative
of any other
person?
(yes/no)
Did this
person
provide
more than
50% of his/
her own
support?
(yes,no,n/a)
Did this
person
have less
than $4,300
of income?
(yes,no,n/a)
Did the
taxpayer(s)
provide more
than 50% of
support for
this person?
(yes/no/n/a)
Did the
taxpayer(s)
pay more than
half the cost of
maintaining a
home for this
person?
(yes/no)
Page 2
Catalog Number 52121E www.irs.gov
Form
13614-C (Rev. 10-2020)
Check appropriate box for each question in each section
Yes No Unsure Part III – Income – Last Year, Did You (or Your Spouse) Receive
1. (B) Wages or Salary? (Form W-2) If yes, how many jobs did you have last year?
2. (A) Tip Income?
3. (B) Scholarships? (Forms W-2, 1098-T)
4. (B) Interest/Dividends from: checking/savings accounts, bonds, CDs, brokerage? (Forms 1099-INT, 1099-DIV)
5. (B) Refund of state/local income taxes? (Form 1099-G)
6. (B) Alimony income or separate maintenance payments?
7. (A) Self-Employment income? (Form 1099-MISC, 1099-NEC, cash, virtual currency, or other property or services)
8. (A) Cash/check/virtual currency payments, or other property or services for any work performed not reported on Forms W-2 or 1099?
9. (A) Income (or loss) from the sale or exchange of Stocks, Bonds, Virtual Currency or Real Estate? (including your home) (Forms 1099-S,1099-B)
10. (B) Disability income? (such as payments from insurance, or workers compensation) (Forms 1099-R, W-2)
11. (A) Retirement income or payments from Pensions. Annuities, and or IRA? (Form 1099-R)
12. (B) Unemployment Compensation? (Form 1099G)
13. (B) Social Security or Railroad Retirement Benefits? (Forms SSA-1099, RRB-1099)
14. (M) Income (or loss) from Rental Property?
15. (B) Other income? (gambling, lottery, prizes, awards, jury duty, virtual currency, Sch K-1, royalties, foreign income, other property or services,
etc.) Specify
Yes No Unsure
Part IV – Expenses – Last Year, Did You (or Your Spouse) Pay
1. (B) Alimony or separate maintenance payments? If yes, do you have the recipient’s SSN? Yes No
2. Contributions to a retirement account? IRA (A) Roth IRA (B) 401K (B) Other
3. (B) College or post secondary educational expenses for yourself, spouse or dependents? (Form 1098-T)
4. Any of the following? (A) Medical & Dental (including insurance premiums) (A) Mortgage Interest (Form 1098)
(A) Taxes (State, Real Estate, Personal Property, Sales) (B) Charitable Contributions
5. (B) Child or dependent care expenses such as daycare?
6. (B) For supplies used as an eligible educator such as a teacher, teacher’s aide, counselor, etc.?
7. (A) Expenses related to self-employment income or any other income you received?
8. (B) Student loan interest? (Form 1098-E)
Yes No Unsure
Part V – Life Events – Last Year, Did You (or Your Spouse)
1. (A) Have a Health Savings Account? (Forms 5498-SA, 1099-SA, W-2 with code W in box 12)
2. (A) Have credit card or mortgage debt cancelled/forgiven by a lender or have a home foreclosure? (Forms 1099-C, 1099-A)
3. (A) Adopt a child?
4. (B) Have Earned Income Credit, Child Tax Credit or American Opportunity Credit disallowed in a prior year? If yes, for which tax year?
5. (A) Purchase and install energy-efficient home items? (such as windows, furnace, insulation, etc.)
6. (A) Receive the First Time Homebuyers Credit in 2008?
7. (B) Make estimated tax payments or apply last year’s refund to this year’s tax? If so how much?
8. (A) File a federal return last year containing a “capital loss carryover” on Form 1040 Schedule D?
9. (A) Have health coverage through the Marketplace (Exchange)? [Provide Form 1095-A]
10. (B) Receive an Economic Impact Payment (stimulus) in 2020?
Page 3
Catalog Number 52121E www.irs.gov
Form
13614-C (Rev. 10-2020)
Additional Information and Questions Related to the Preparation of Your Return
1. Provide an email address (optional) (this email address will not be used for contacts from the Internal Revenue Service)
2. Presidential Election Campaign Fund (If you check a box, your tax or refund will not change)
Check here if you, or your spouse if filing jointly, want $3 to go to this fund
You Spouse
3. If you are due a refund, would you like: a. Direct deposit
Yes No
b. To purchase U.S. Savings Bonds
Yes No
c. To split your refund between different accounts
Yes No
4. If you have a balance due, would you like to make a payment directly from your bank account?
Yes No
5. Did you live in an area that was declared a Federal disaster area? If yes, where?
Yes No
6. Did you, or your spouse if filing jointly, receive a letter from the IRS?
Yes No
7. Would you say you can carry on a conversation in English, both understanding & speaking? Very well Well Not well Not at all Prefer not to answer
8. Would you say you can read a newspaper or book in English? Very well Well Not well Not at all Prefer not to answer
9. Do you or any member of your household have a disability? Yes No Prefer not to answer
10. Are you or your spouse a Veteran from the U.S. Armed Forces? Yes No Prefer not to answer
11. Your race?
American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White Prefer not to answer
12. Your spouse’s race?
American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White Prefer not to answer
No spouse
13. Your ethnicity? Hispanic or Latino Not Hispanic or Latino Prefer not to answer
14. Your spouse’s ethnicity?
Hispanic or Latino
Not Hispanic or Latino Prefer not to answer No spouse
Additional comments
Privacy Act and Paperwork Reduction Act Notice
The Privacy Act of 1974 requires that when we ask for information we tell you our legal right to ask for the information, why we are asking for it, and how it will be used. We must also tell you what could happen if we
do not receive it, and whether your response is voluntary, required to obtain a benefit, or mandatory. Our legal right to ask for information is 5 U.S.C. 301. We are asking for this information to assist us in contacting
you relative to your interest and/or participation in the IRS volunteer income tax preparation and outreach programs. The information you provide may be furnished to others who coordinate activities and staffing at
volunteer return preparation sites or outreach activities. The information may also be used to establish effective controls, send correspondence and recognize volunteers. Your response is voluntary. However, if you
do not provide the requested information, the IRS may not be able to use your assistance in these programs. 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
Many free tax preparation sites operate by receiving grant money or other federal financial assistance. The data from the following questions may be used by
this site to apply for these grants or to support continued receipt of financial funding . Your answer will be used only for statistical purposes. These questions
are optional.
Catalog Number 71414A www.irs.gov
Form
15080 (EN-SP) (Rev. 7-2020)
Form 15080 (EN-SP)
(July 2020)
Department of the Treasury - Internal Revenue Service
Consent to Disclose Tax Return Information to
VITA/TCE Tax Preparation Sites
Federal Disclosure:
Federal law requires this consent form be provided to you. Unless authorized by law, we cannot disclose your tax
return information to third parties for purposes other than the preparation and filing of your tax return without your
consent. If you consent to the disclosure of your tax return information, Federal law may not protect your tax return
information from further use or distribution.
You are not required to complete this form to engage our tax return preparation services. If we obtain your signature
on this form by conditioning our tax return preparation services on your consent, your consent will not be valid. If you
agree to the disclosure of your tax return information, your consent is valid for the amount of time that you specify. If
you do not specify the duration of your consent, your consent is valid for one year from the date of signature.
Terms:
Global Carry Forward of data allows TaxSlayer LLC, the provider of the VITA/TCE tax software, to make your tax
return information available to ANY volunteer site participating in the IRS's VITA/TCE program that you select to
prepare a tax return in the next filing season. This means you will be able to visit any volunteer site using TaxSlayer
next year and have your tax return populate with your current year data, regardless of where you filed your tax
return this year. This consent is valid through November 12, 2022.
The tax return information that will be disclosed includes, but is not limited to, demographic, financial and other
personally identifiable information, about you, your tax return and your sources of income, which was input into the
tax preparation software for the purpose of preparing your tax return. This information includes your name, address,
date of birth, phone number, SSN, filing status, occupation, employer's name and address, and the amounts and
sources of income, deductions and credits that were claimed on, or contained within, your tax return. The tax return
information that will be disclosed also includes the name, SSN, date of birth, and relationship of any dependents that
were claimed on your tax return.
You do not need to provide consent for the VITA/TCE partner preparing your tax return this year. Global Carry
Forward will assist you only if you visit a different VITA or TCE partner next year that uses TaxSlayer.
Limitation on the Duration of Consent: I/we, the taxpayer, do not wish to limit the duration of the consent of the
disclosure of tax return information to a date earlier than presented above (November 12, 2022). If I/we wish to limit
the duration of the consent of the disclosure to an earlier date, I/we will deny consent.
Limitation on the Scope of Disclosure: I/we, the taxpayer, do not wish to limit the scope of the disclosure of tax
return information further than presented above. If I/we wish to limit the scope of the disclosure of tax return
information further than presented above, I/we will deny consent.
Consent:
I/we, the taxpayer, have read the above information.
I/we hereby consent to the disclosure of tax return information described in the Global Carry Forward terms above
and allow the tax return preparer to enter a PIN in the tax preparation software on my behalf to verify that I/we
consent to the terms of this disclosure.
Primary taxpayer printed name and signature
Date
Secondary taxpayer printed name and signature Date
If you believe your tax return information has been disclosed or used improperly in a manner unauthorized by law or
without your permission, you may contact the Treasury Inspector General for Tax Administration (TIGTA) by
telephone at 1-800-366-4484, or by e-mail at complaints@tigta.treas.gov.
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Form 13614-C: IntakeInterview & Quality Review Sheet (United Way of Southeast Louisiana)

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Completed 11 March 2021

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