Federal VITA Intake/Interview & Quality Review Sheet
Extracted from PDF file 2021-federal-form-13614-c.pdf, last modified July 2021
VITA Intake/Interview & Quality Review SheetForm 13614-C Department of the Treasury - Internal Revenue Service OMB Number 1545-1964 Intake/Interview & Quality Review Sheet (October 2021) • Please complete pages 1-4 of this form. You will need: • Tax Information such as Forms W-2, 1099, 1098, 1095. • You are responsible for the information on your return. Please provide complete and accurate information. • 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. • If you have questions, please ask the IRS-certified volunteer preparer. Volunteers are trained to provide high quality service and uphold the highest ethical standards. To report unethical behavior to the IRS, email us at [email protected] 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 Best contact number 2. Your spouse’s first name M.I. Last name Best contact number 3. Mailing address Apt # City 6. Last year, were you: Yes No b. Totally and permanently disabled 9. Last year, was your spouse: 7. Your spouse’s Date of Birth 8. Your spouse’s job title b. Totally and permanently disabled 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? 4. Your Date of Birth 5. Your job title Are you a U.S. citizen? Yes No Is your spouse a U.S. citizen? Yes No State ZIP code a. Full-time student c. Legally blind a. Full-time student c. Legally blind Yes Yes Yes Yes No No No No Yes No 12. Provide an email address (optional) (this email address will not be used for contacts from the Internal Revenue Service) Part II – Marital Status and Household Information Never Married Married (This includes registered domestic partnerships, civil unions, or other formal relationships under state law) Yes No a. If Yes, Did you get married in 2021? Yes No b. Did you live with your spouse during any part of the last six months of 2021? Date of final decree Divorced Legally Separated Date of separate maintenance decree Year of spouse’s death Widowed 1. As of December 31, 2021, what was your marital status? 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 Name (first, last) Do not enter your name or spouse’s name below (a) Catalog Number 52121E Date of Birth (mm/dd/yy) (b) Relationship to you (for example: son, daughter, parent, none, etc) (c) If additional space is needed check here To be completed by a Certified Volunteer Preparer Number of US months Citizen lived in (yes/no) your home last year (d) and list on page 3 (e) Resident of US, Canada, or Mexico last year (yes/no) Single or Married as of 12/31/21 (S/M) Full-time Student last year (yes/no) Totally and Permanently Disabled (yes/no) (f) (g) (h) (i) www.irs.gov 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) Form 13614-C (Rev. 10-2021) Page 2 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, etc.) 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 or repayments to a retirement account? IRA (A) 401K (B) Roth IRA (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, student loan 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 2021? 11. (B) Receive Advanced Child Tax Credit payments? Catalog Number 52121E www.irs.gov Form 13614-C (Rev. 10-2021) Page 3 Additional Information and Questions Related to the Preparation of Your Return 1. Would you like to receive written communications from the IRS in a language other than English? Yes No If yes, which language? 2. Presidential Election Campaign Fund (If you check a box, your tax or refund will not change) You Spouse Check here if you, or your spouse if filing jointly, want $3 to go to this fund 3. If you are due a refund, would you like: a. Direct deposit b. To purchase U.S. Savings Bonds c. To split your refund between different accounts Yes No Yes No 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 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. 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? Not Hispanic or Latino Prefer not to answer No spouse Hispanic or Latino 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 Catalog Number 52121E www.irs.gov Form 13614-C (Rev. 10-2021) Department of the Treasury - Internal Revenue Service Form 15080 (October 2021) 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 30, 2023. 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 30, 2023). 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 [email protected] Catalog Number 39573K www.irs.gov Form 15080 (10-2021) Previously identified as Form 15080 (en-sp)
Form 13614-C (Rev. 10-2021)
More about the Federal Form 13614-C Individual Income Tax TY 2021
Intake information form for taxpayers using a volunteer tax preparation site. This form is also available in other languages.
We last updated the VITA Intake/Interview & Quality Review Sheet in January 2022, so this is the latest version of Form 13614-C, fully updated for tax year 2021. You can download or print current or past-year PDFs of Form 13614-C directly from TaxFormFinder. You can print other Federal tax forms here.
Related Federal Individual Income Tax Forms:
|Form Code||Form Name|
|Form 13614-C (PT)||Intake/Interview & Quality Review Sheet - Portuguese|
|Form 13614-C (HT)||Intake/Interview & Quality Review Sheet - Creole-French|
|Form 13614-C (KR)||Intake/Interview & Quality Review Sheet - Korean|
|Form 13614-C (PL)||Intake/Interview & Quality Review Sheet - Polish|
The Internal Revenue Service usually releases income tax forms for the current tax year between October and January, although changes to some forms can come even later. We last updated Federal Form 13614-C from the Internal Revenue Service in January 2022.
About the Individual Income Tax
The IRS and most states collect a personal income tax, which is paid throughout the year via tax withholding or estimated income tax payments.
Most taxpayers are required to file a yearly income tax return in April to both the Internal Revenue Service and their state's revenue department, which will result in either a tax refund of excess withheld income or a tax payment if the withholding does not cover the taxpayer's entire liability. Every taxpayer's situation is different - please consult a CPA or licensed tax preparer to ensure that you are filing the correct tax forms!
Historical Past-Year Versions of Federal Form 13614-C
We have a total of four past-year versions of Form 13614-C in the TaxFormFinder archives, including for the previous tax year. Download past year versions of this tax form as PDFs here:
Form 13614-C (Rev. 10-2021)
Form 13614-C (Rev. 10-2020)
Form 13614-C (Rev. 10-2019)
Form 13614-C (Rev. 10-2018)
While we do our best to keep our list of Federal Income Tax Forms up to date and complete, we cannot be held liable for errors or omissions. Is the form on this page out-of-date or not working? Please let us know and we will fix it ASAP.