VITA Intake Form 13614-C Intake/Interview & Quality Review (English)

Department of the Treasury - Internal Revenue Service
Intake/Interview & Quality Review Sheet
- You will need:
- • 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.
- • 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.
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?
YesNo
2. Your spouse’s first name
M.I.
Spouse's Last name
Daytime telephone number
Is your spouse a U.S. citizen?
YesNo
3. Mailing address
Apt #
City
State
ZIP code
4. Your Date of Birth
MonthDayYear
Date
5. Your job title
6. Last year, were you:
a. Full-time student
YesNo
b. Totally and permanently disabled
YesNo
c. Legally blind
YesNo
7. Your spouse’s Date of Birth
MonthDayYear
Date
8. Your spouse’s job title
9. Last year, was your spouse:
a. Full-time student
YesNo
b. Totally and permanently disabled
YesNo
c. Legally Blind
YesNo
10. Can anyone claim you or your spouse as a dependent?
YesNoUnsure
11. Have you, your spouse, or dependents been a victim of tax related identity theft or been issued an Identity Protection PIN?
YesNo
Part II – Marital Status and Household Information
1. As of December 31, 2020, what was your marital status
Never MarriedMarriedDivorcedLegally SeperatedWidowed
If Married (This includes registered domestic partnerships, civil unions, or other formal relationships under state law)
a. If married, did you get married in 2020
YesNo
b. Did you live with your spouse during any part of the last six months of 2020?
YesNo
Date of Final Decree
MonthDayYear
Date
Date of separate maintenance decree
MonthDayYear
Date
Year of Spouse's Death
MonthDayYear
Date

2. List the names below of (1) everyone who lived with you last year (other than your spouse) and (2) 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)	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 12/31/2020 (S/M) (g)	Full-time Student last year (yes/no) (h)	Totally and Permanently Disabled (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)
Dependent 1
Dependent 2
Dependent 3
Dependent 4

If additional space is needed:
check here and list on page 3
Part III – Income – Last Year, Did You (or Your Spouse) Receive

Check appropriate box for each question in each section

	Yes	No	Unsure
1. (B) Wages or Salary? (Form W-2)	1	2	3
2. (A) Tip Income?	4	5	6
3. (B) Scholarships? (Forms W-2, 1098-T)	7	8	9
4. (B) Interest/Dividends from: checking/savings accounts, bonds, CDs, brokerage? (Forms 1099-INT, 1099-DIV)	10	11	12
5. (B) Refund of state/local income taxes? (Form 1099-G)	13	14	15
6. (B) Alimony income or seperate maintenance payments?	16	17	18
7. (A) Self-Employment Income? (Form 1099-MISC, 1099-NEC, cash, virtual currency, or other property or services)	19	20	21
8. (A) Cash/check/virtual currency payments, or other property or services for any work performed not reported on Forms W-2 or 1099?	22	23	24
9. (A) Income (or loss) from sale or exchange of Stocks, Bonds, Virtual Currency or Real Estate? (including your home ) (Forms 1099-S, 1099-B)	25	26	27
10. (B) Disability Income? (such as payments from insurance, or workers compensation) (Forms 1099-R, W-2)	28	29	30
11. (A) Retirement Income or payments from Pensions, Annuities, and/or IRA? (Form 1099-R)	31	32	33
12. (B) Unemployment Compensation? (Form 1099G)	34	35	36
13. (B) Social Security or Railroad Retirement Benefits? (Forms SSA-1099, RRB-1099)	37	38	39
14. (M) Income (or loss) from Rental Property?	40	41	42
15. (B) Other Income? Gambling, lottery, prizes, awards, jury duty, virtual currency, Sch K-1, royalties, foreign income, other property or services, etc.)	43	44	45

1. (B) Wages or Salary? (Form W-2) If yes, how many jobs did you have last year?
15. (B) Other income? gambling, lottery, prizes, awards, jury duty, virtual currency, Sch K-1, royalties, foreign income, other property or services, etc.) Specify

Part IV – Expenses – Last Year, Did You (or Your Spouse) Pay

	Yes	No	Unsure
1. (B) Alimony or seperate maintenance payments?	46	47	48
2. Contributions to a retirement account?	49	50	51
3. (B) College or Post-Secondary Educational Expenses for yourself, spouse or dependents? (Form 1098-T)	52	53	54
4. Any of the Following? See question below	55	56	57
5. (B) Child and Dependent Care Expenses such as daycare?	58	59	60
6. (B) For supplies used as an eligible educator such as a teacher, teacher's aide, counselor, etc.?	61	62	63
7. (A) Expenses related to self-employment income or any other income you received?	64	65	66
8. (B) Student loan interest? (Form 1098-E)	67	68	69

1. (B) Alimony or separate maintenance payments? If yes, do you have the recipient’s SSN?
YesNo
2. If you contributed to a retirement account, please select the type(s) of account(s):
IRA (A)401K (B)Roth IRAOther
4. Do You Have 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

Part V – Life Events – Last Year, Did You (or Your Spouse)

	Yes	No	Unsure
1. (A) Have a Health Savings Account? (Forms 5498-SA, 1099-SA, W-2 with code W in box	70	71	72
2. (A) Have credit card or mortgage debt cancelled/forgiven by a lender or have a home foreclosure? (Forms 1099-C, 1099-A)	73	74	75
3. (A) Adopt a child	76	77	78
4. (B) Have Earned Income Credit, Child Tax Credit or American Opportunity Credit disallowed in a prior year?	79	80	81
5. (A) Purchase and install energy-efficient home items? (such as windows, furnace, insulation, etc.)	82	83	84
6. (A) Receive the First Time Homebuyers Credit in 2008?	85	86	87
7. (B) Make estimated tax payments or apply last year's refund to this year's tax?	88	89	90
8. (A) File a federal return last year containing a "capital loss carryover" on Form 1040 Schedule D?	91	92	93
9. (A) Have health coverage through the Marketplace (Exchange)? [Provide Form 1095-A]	94	95	96
10. (B) Receive an Economic Impact Payment (stimulus) in 2020?	97	98	99

4. (B) Have Earned Income Credit, Child Tax Credit or American Opportunity Credit disallowed in a prior year? If yes, for which tax year?
7. (B) Make estimated tax payments or apply last year’s refund to this year’s tax? If so how much?
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)
example@example.com
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
YouSpouse
3. If you are due a refund, would you like
Direct Deposit:
YesNo
b. To purchase U.S. Savings Bonds
YesNo
c. To split your refund between different accounts
YesNo
4. If you have a balance due, would you like to make a payment directly from your bank account?
YesNo
5. Did you live in an area that was declared a Federal disaster area?
YesNo
5. If yes, where?
6. Did you, or your spouse if filing jointly, receive a letter from the IRS?
YesNo
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 wellWellNot wellNot at allPrefer not to answer
8. Would you say you can read a newspaper or book in English?
Very wellWellNot wellNot at allPrefer not to answer
9. Do you or any member of your household have a disability?
YesNoPrefer not to answer
10. Are you or your spouse a Veteran from the U.S. Armed Forces?
YesNoPrefer not to answer
11. Your Race?
American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or other Pacific IslanderWhitePrefer not to answer
12. Your spouse's race?
American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or other Pacific IslanderWhitePrefer not to answerNo spouse
13. Your ethnicity?
Hispanic or LatinoNot Hispanic or LatinoPrefer not to answer
14. Your ethnicity?
Hispanic or LatinoNot Hispanic or LatinoPrefer not to answerNo 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
Department of the Treasury - Internal Revenue Service
Consent to Disclose Tax Return Information to VITA/TCE Tax Preparation Sites
Form 15080 (EN-SP) (July 2020)
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
Signature
Clear
Date
MonthDayYear
Date
Secondary taxpayer printed name and signature
Signature
Clear
Date
MonthDayYear
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.
(Rev. 7-2020) Form 15080 (EN-SP)
Should be Empty:

Intake/Interview & Quality Review Sheet

Part II – Marital Status and Household Information

Part III – Income – Last Year, Did You (or Your Spouse) Receive

Additional Information and Questions Related to the Preparation of Your Return

Privacy Act and Paperwork Reduction Act Notice

Consent to Disclose Tax Return Information to VITA/TCE Tax Preparation Sites

Federal Disclosure:

Terms:

Consent: