All the Social Security numbers and any other tax identification numbers, such as employer identification numbers (EIN) will contain "X"s for part of the number. Replace only the "X"s used in all the social security numbers and all the employer identification numbers with 001234.Use all other numbers as they are given.

Tori and Carena Clark qualify for the Child Tax Credit so you will need to enter $2,000 on Form 1040, page 2 for the Child Tax Credit line.Form 8812 is not necessary.

Make sure to hand in only what would go to the IRS and make sure it is in the correct order!

The Clarks are expecting a $2,790 refund.

Exercise 4 - Clark Intake and Interview Sheet, page 1 of 4 Department of the Treasury - Internal Revenue Service Form 13614-C (Rev. XX-XXXX) Intake/Interview & Quality Review Sheet OMB # 1545-1964 Section A. You should complete Pages 1-3 Thank you for allowing us to prepare your tax return. You are responsible for the information on your return so please provide complete and accurate information to the certified tax preparer. If you have any questions please ask your preparer. You will need your: Tax information such as Forms W-2, 1099, 1098. Social security cards or ITIN letters for you and all persons on your tax return. Proof of Identity (such as a valid drivers license or other government issued picture ID). Part I. Your Personal Information 5. Your Date of Birth 12/30/1971 X Age 41 9. Spouse's Date of Birth X Age 40 12/14/1973 M. I. Last Name C CLARK M. I. Last Name S STEPHENS Apt# City Your City Are you a U.S. Citizen? Yes No Is spouse a U.S. Citizen? Yes No State Zip Code YS Your ZIP R of A 7- FT 22 -1 1 1. Your First Name WINDSOR 2. Spouse's First Name TEENA 3. Mailing Address 11093 BRANDON WAY 4. Contact Information Phone: 704-555-XXXX YS = Your State Cell Phone: E-mail: Are you: 7. Legally Blind 8. Totally and Permanently Disabled Is Spouse: 11. Legally Blind 12. Totally and Permanently Disabled 6. Your Job Title SUPERVISOR 10. Spouse's Job Title OFFICE ASSISTANT 13. Can anyone claim you or your spouse on their tax return? Yes No Yes Yes Yes Yes No No No No Unsure Part II. Marital Status and Household Information 1. As of December 31, 2011, X were you? Single Married: Did you live with your spouse during any part of the last six months of 2011? X D Yes No Divorced or Legally Separated: Date of final decree or separate maintenance agreement: Widowed: Year of spouse's death: X (other than you or spouse). Also list anyone who 2. List names below of everyone who lived in your home in 2011 lived outside of your home that you supported during 2011. X If additional space is needed please check here list on page 3. (a) TORI CLARK (Age 14) (Age 2) CARENA CLARK Received less than $3700 income in 2011 (yeso) Relationship to you (e.g. daughter, son, mother, sister, none) Number of months lived in your home in 2011 US Citizen or resident of the US, Canada or Mexico in 2011 (yeso) Marital Status as of 12/31/11 (S/M) Fulltime student in 2011 (yeso) (b) (c) (d) (e) (f) (g) 2/10/98 XX DAUGHTER 12 Y S Y Y XX 7/24/10 DAUGHTER 12 Y S N Y Date of Birth (mm/dd/yy) as Name (first, last) Do not enter your name or spouse's name below. and (h) Volunteers assisting with preparing your return are trained to provide high quality service and uphold the highest ethical standards. To report unethical behavior to IRS, email us at wi.voltax@irs.gov or call toll free 1-877-330-1205. To check the status of your REFUND visit \"Where's My Refund?\" on www.irs.gov or call 1-800-829-1954 for assistance. Form 13614-C (Rev. XX-XXXX) 1 Catalog Number 52121E Basic - Clark 27 Exercise 4 - Clark Intake and Interview Sheet, page 2 of 4 Section A. Please complete - check Yes, No or Unsure to all questions below. Please ask if you need help. Part III. Income - In 2011, X did you (or your spouse) receive: 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Wages or Salary? (Form W-2) Tip Income? Scholarships? (Forms W-2, 1098-T) Interest/Dividends from: checking/savings accounts, bonds, CDs, brokerage? (Forms 1099-INT, 1099-DIV) Refund of state/local income taxes? (Form 1099-G) Alimony Income? Self-Employment payments (such as cash received for services, small business)? (Form 1099-MISC) Income (or loss) from the sale of Stocks, Bonds or Real Estate (including your home)? (Forms 1099-S, 1099-B) Disability Income (such as payments from insurance or workers compensation)? (Forms 1099-R, W-2) Distributions from Pensions, Annuities, and/or IRA? (Form 1099-R) Unemployment Compensation? (Form 1099-G) Social Security or Railroad Retirement Benefits? (Forms SSA-1099, RRB-1099) Income (or loss) from Rental Property? Other Income: (gambling, lottery, prizes, awards, jury duty, etc.) Specify: (Forms W-2 G, 1099-MISC) R of A 7- FT 22 -1 1 Yes No Unsure 1. 2. 3. 4. Part IV. Expenses - In 2011 X Did you (or your spouse) pay: D Yes No Unsure 1. Alimony: If yes, do you have the recipient's SSN? Yes No 2. Contributions to a retirement account? IRA Roth IRA 401K Other 3. Educational expenses paid for yourself, spouse or dependents, such as tuitions, books, fees, etc.? (Form 1098-T) 4. Unreimbursed employee business expenses (such as teacher supplies, uniforms or mileage)? 5. Medical expenses (including health insurance premiums)? 6. Home mortgage interest? (Form 1098) 7. Real estate taxes for your home or personal property taxes for your vehicle? (Form 1098) 8. Charitable contributions? 9. Child/dependent care expenses, such as day-care? Part V. Life Events - In 2011 X Did you (or your spouse): Yes No Unsure Have a Health Savings Account? (Forms 5498-SA, Form 1099-SA) Have debt from a mortgage or credit card canceled/forgiven by a commercial lender? (Form 1099-C) Buy, sell or have a foreclosure of your home? (Form 1099-A) Have Earned Income Credit (EIC) disallowed in a prior year? If yes, for which tax year? Purchase and install energy efficient home items (such as windows, furnace, insulation, etc.)? Live in an area that was affected by a natural disaster? If yes, where? Receive the First Time Homebuyers Credit in 2008? Pay any student loan interest? (Form 1098-E) Make estimated tax payments or apply last year's refund to your 2011 tax? If so how much? as 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Attend school as a full time student? (Form 1098-T) 11. Adopt a child? X federal tax return containing a \"capital loss carryover\" on Form 1040 Schedule D? 12. File a 2010 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 Catalog Number 52121E 28 Basic - Clark Form 13614-C (Rev. XX-XXXX) 2 Exercise 4 - Clark Intake and Interview Sheet, page 3 of 4 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? NONE Are you or a member of your household considered disabled? Yes No If you are due a refund or have a balance due: Ask your preparer about Direct Deposit. It is the fastest, easiest way to receive your tax refund. An e-filed return means a fast refund. Taxpayers who combine e-file and Direct Deposit can get their refunds 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? No If you are due a refund, would you like information on how to purchase U.S. Savings Bonds? Yes No If you are due a refund, would you like information on how to split your refund between accounts? Yes No If you have a balance due, would you like to make a payment directly from your bank account? Yes No D Additional comments: R of A 7- FT 22 -1 1 Yes STOP HERE! as Thank you for completing this form. Please give this form to the certified volunteer preparer for use in preparing your return. Your Civil Rights are Protected: It is the Internal Revenue Service's mission to provide America's taxpayers top quality service by helping them understand and meet their tax responsibilities and by applying the tax law with integrity and fairness to all. Under no circumstances will the Internal Revenue Service tolerate discrimination by its employees, grantees, contractors, and/or subcontractors. NO ONE shall be excluded from participating in, be denied the benefits of, or be subject to discrimination because of race, color, sex, national origin, disability, reprisal, or age in programs or activities funded by the Department of Treasury - Internal Revenue Service. Any person who believes that he/she has been discriminated against on the basis of race, color, sex, national origin, disability, reprisal or age in programs or activities receiving financial assistance (e.g. Low-Income Tax Clinics, Tax Counseling for the Elderly) from the Department of Treasury IRS, may submit a written complaint to: National Headquarters;Office of Equity, Diversity & Inclusion; Internal Revenue Service; Attn: Director, Civil Rights Division (External Civil Rights Team); 1111 Constitution Ave., NW Room 2422; Washington, DC 20224. 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. Form 13614-C (Rev. XX-XXXX) 3 Catalog Number 52121E Basic - Clark 29 Exercise 4 - Clark Intake and Interview Sheet, page 4 of 4 Section B. For Certified Volunteer Preparer Completion Remember: You are the link between the taxpayer's information and a correct tax return. Verify the taxpayer's information on pages 1, 2 & 3 is complete. All questions must be discussed with the taxpayer and all \"Unsure\" responses should be changed to \"Yes\" or \"No\". Must be completed by Certified Volunteer only if persons are listed in Part II Question 2 Check if persons are listed in Part II Question 2 Yes Yes No No No N/A No 2. Were any of the persons listed in Part II, Question 2, totally and permanently disabled? If yes, which ones: 3. Did any of the persons listed in Part II, Question 2 provide more than 50% of their own support? If yes, which ones: 4. Did the taxpayer provide more than half the support for each of the persons in Part II, Question 2? If yes, which ones: 5. Did the taxpayer? pay over half the cost of maintaining a home for any of the persons in Part II, Question 2? If yes, which ones: as Yes 1. Can anyone else claim any of the persons listed in Part II, Question 2, as a dependent on their return? If yes, which ones: Confirm each item after reviewing the tax return and verifying that it reflects correct tax law application to the information provided by the taxpayer. 1. Sections A & B of this form are complete. 2. Taxpayer's identity, address and phone numbers were verified. 3. Names, SSN or ITINs, and dates of birth of taxpayer, spouse and dependents match the supporting documents. 4. Filing Status is correctly determined. R of A 7- FT 22 -1 1 Yes No D Yes Section C. For Certified Quality Reviewer Completion Reminders Use Publication 4012, Volunteer Resource Guide and Publication 17, Your Federal Income Tax in making tax law determinations. 5. Personal and Dependency Exemptions are entered correctly on the return. 6. All information shown on source documents and noted in Section A, Part III is included on the tax return. 7. Any Adjustments to Income are correctly reported. 8. Standard, Additional or Itemized Deductions are correct. 9. All credits are correctly reported. 10. Withholding shown on Forms W-2, 1099 and Estimated Tax Payments are correctly reported. All tax law issues above have been addressed and necessary changes have been made. If direct deposit or debit was elected, checking/saving account and routing information match the supporting documents. Correct SIDN and EFIN are shown on the return. Additional Tax Preparer Notes: Catalog Number 52121E 30 Basic - Clark Form 13614-C (Rev. XX-XXXX) 4 051-XX-XXXX 052-XX-XXXX Windsor C. Clark Teena S. Stephens Windsor C. Clark gxxt fA fx{x 053-XX-XXXX 054-XX-XXXX Tori Clark Carena C. Clark Tori Clark Carena C. Clark Interview Notes - Clark 2 years ago X Windsor has one daughter from his previous marriage. Windsor and Teena were married on June 9, 2010. Windsor's daughter, Tori, lived with him for the entire year. Tori's mother provided half of her support but will not claim Tori as a dependent on her tax return. Teena Clark, whose maiden name is Stephens, tells you she has not notified the Social Security Administration of her name change. (You should suggest that she contact the Social Security Administration to correct her name to match her social security number. This will prevent delays in processing the return and issuing refunds. It also safeguards any future social security benefits.) If there is a refund, the Clarks want it sent to their home. If they owe more taxes, they will pay by check. Neither wants to contribute to the Presidential Election Campaign Fund. The Clarks' correct street address is 110 Brandon Avenue. Note: Before completing Section B of Form 13614-C, go over Parts I-V with the taxpayer. Be sure to note anything on the intake sheet that changes as a result of this interview. In addition, to ensure the accuracy of the taxpayer's return, a certified volunteer should complete Section C the Reviewer Checklist. Basic - Clark 31 a Employee's social security number b Employer identification number (EIN) 051-XX-XXXX OMB No. 1545-0008 Safe, accurate, FAST! Use Visit the IRS website at www.irs.gov/efile 1 Wages, tips, other compensation 2 Federal income tax withheld 3 Social security wages 4 Social security tax withheld $20,187.37 13-0XXXXXX c Employer's name, address, and ZIP code $3,562.97 $885.67 $21,087.37 MARC TECKTRONICS P.O. Box 1105 Charleston, SC 29403 5 Medicare wages and tips 6 Medicare tax withheld $305.77 $21,087.37 7 Social security tips d Control number 8 Allocated tips 9 e Employee's first name and initial 10 Dependent care benefits Suff. 11 Nonqualified plans Last name Windsor C. Clark 3707 Minute Way Your City, State and Zip Code 13 Statutory employee Retirement plan 12a See instructions for box 12 C o d e Third-party sick pay D 12b $900.00 C o d e 12c 14 Other C o d e 12d C o d e f Employee's address and ZIP code 15 State YS Form Employer's state ID number 16 State wages, tips, etc. 17 State income tax $20,187.37 $423.00 05-1881172 W-2 Wage and Tax Statement 18 Local wages, tips, etc. 2 2011 19 Local income tax 20 Locality name Department of the TreasuryInternal Revenue Service Copy BTo Be Filed With Employee's FEDERAL Tax Return. This information is being furnished to the Internal Revenue Service. a Employee's social security number 052-XX-XXXX OMB No. 1545-0008 b Employer identification number (EIN) Safe, accurate, FAST! Use Visit the IRS website at www.irs.gov/efile 1 Wages, tips, other compensation 2 Federal income tax withheld $33,959.24 13-1XXXXXX $1,560.25 c Employer's name, address, and ZIP code 3 Social security wages G.K. Associates, Inc. 618 Moss Lane Statesville, NC 28677 5 Medicare wages and tips d Control number 9 e Employee's first name and initial 4 Social security tax withheld $1,426.08 $33,959.24 6 Medicare tax withheld $492.34 $33,959.24 7 Social security tips 8 Allocated tips 10 Dependent care benefits Suff. 11 Nonqualified plans Last name Teena Clark 110 Brandon Avenue Your City, State and Zip Code 13 Statutory employee Retirement plan 12a See instructions for box 12 C o d e Third-party sick pay 12b C o d e 12c 14 Other C o d e 12d C o d e f Employee's address and ZIP code 15 State YS Form Employer's state ID number 05-24567812 W-2 Wage and Tax Statement 16 State wages, tips, etc. 17 State income tax $33,959.24 $779.00 2 2011 Copy BTo Be Filed With Employee's FEDERAL Tax Return. This information is being furnished to the Internal Revenue Service. 32 Basic - Clark 18 Local wages, tips, etc. 19 Local income tax 20 Locality name Department of the TreasuryInternal Revenue Service CORRECTED (if checked) PAYER'S name, street address, city, state, ZIP code, and telephone no. 1a Total ordinary dividends ASP UNITED BANK 11000 Cypress Blvd. Philadelphia, PA 19102 1b Qualified dividends PAYER'S federal identification number $ 13-2XXXXXX 052-XX-XXXX RECIPIENT'S name Dividends and Distributions 2011 X 187.00 $ RECIPIENT'S identification number OMB No. 1545-0110 Form 1099-DIV 2a Total capital gain distr. 2b Unrecap. Sec. 1250 gain $ $ 2c Section 1202 gain 2d Collectibles (28%) gain $ $ 3 Nondividend distributions 4 Federal income tax withheld 19.00 $ $ Teena Clark 5 Investment expenses $ 6 Foreign tax paid Street address (including apt. no.) 110 Brandon Way 7 Foreign country or U.S. possession $ City, state, and ZIP code Your City, State and ZIP Code 8 Cash liquidation distributions 9 Noncash liquidation distributions $ $ Account number (see instructions) Form 1099-DIV (keep for your records) Copy B For Recipient This is important tax information and is being furnished to the Internal Revenue Service. If you are required to file a return, a negligence penalty or other sanction may be imposed on you if this income is taxable and the IRS determines that it has not been reported. Department of the Treasury - Internal Revenue Service CORRECTED (if checked) PAYER'S name, street address, city, state, ZIP code, and telephone no. P & A Financial Corporation 124 E. Main Street Cherryville, NC 28021 Payer's RTN (optional) 13-3XXXXXX $ 217.00 Interest Income 2 Early withdrawal penalty RECIPIENT'S identification number 051-XX-XXXX Form 1099-INT 3 Interest on U.S. Savings Bonds and Treas. obligations $ Copy B For Recipient This is important tax information and is being furnished to the Internal Revenue Service. If you are $ $ required to file a return, a 6 Foreign tax paid 7 Foreign country or U.S. possession negligence penalty or other sanction may be imposed $ on you if this income is taxable and the IRS 8 Tax-exempt interest 9 Specified private activity bond interest determines that it has not been reported. $ $ 10 Tax-exempt bond CUSIP no. (see instructions) 4 Federal income tax withheld RECIPIENT'S name Windsor C. Clark Street address (including apt. no.) 110 Brandon Way City, state, and ZIP code Your City, State and ZIP Code Account number (see instructions) Form 11 X 1 Interest income $ PAYER'S federal identification number OMB No. 1545-0112 1099-INT (keep for your records) 5 Investment expenses Department of the Treasury - Internal Revenue Service CORRECTED (if checked) PAYER'S name, street address, city, state, ZIP code, and telephone no. 1 Unemployment compensation Employment Security Commission 701 W. Monroe Street Columbia, SC 29201 $ OMB No. 1545-0120 8,250.00 11 X 2 State or local income tax refunds, credits, or offsets $ PAYER'S federal identification number 13-4XXXXXX RECIPIENT'S identification number RECIPIENT'S name Windsor Clark Street address (including apt. no.) 110 Brandon Way City, state, and ZIP code Your City, State and ZIP Code Account number (see instructions) Form 1099-G 051-XX-XXXX 3 Box 2 amount is for tax year Form 1099-G 4 Federal income tax withheld $ 5 ATAA/RTAA payments Certain Government Payments 6 Taxable grants Copy B For Recipient This is important tax information and is being furnished to the $ $ Internal Revenue Service. If you are 7 Agriculture payments 8 If checked, box 2 is required to file a return, trade or business \u001f $ a negligence penalty or income other sanction may be 9 Market gain imposed on you if this income is taxable and $ the IRS determines that 10a State 10b State identification no. 11 State income tax withheld it has not been reported. $ (keep for your records) Department of the Treasury - Internal Revenue Service Basic - Clark 33