Form-13614-C October 2018) Department of the Treasury - Internal Revenue Service OMB Number 1545-1964 Intake/Interview & Quality Review Sheet Please complete pages 1-3 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 p 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 PartI- 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 EMILY 2. Your spouse's first name M.I. Last name Daytime telephone number Are you a U.S. citizen? YOUR PHONE # CLARK No M.I. Last name Daytime telephone number Is your spouse a U.S. citizen? Yes State No 3. Mailing address 129 PENNINGTON PLACE 4. Your Date of Birth 04/29/1978 Apt # City ZIP code YOUR CITY YOUR ZIP Yes X No Yes No Yes No 5. Your job title MED ASSISTANT 6. Last year, were you b. Totally and permanently disabled Yes X No c. Legally blind 9. Last year, was your spouse b. Totally and permanently disabled YesNo c. Legally blind a. Full-time student Yes No 7. Your spouse's Date of Birth 8. Your spouse's job title a. Full-time student Yes No 10. Can anyone claim you or your spouse as a dependent? O 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? Part II Marital Status and Household Information 1. As of December 31, 2018, what Never Married (This includes registered domestic partnerships, civil unions, or other formal relationships under state law) was your marital status? Married a. If Yes, Did you get married in 2018 b. Did you live with your spouse during any part of the last six months of 2018? Yes No No Yes Date of final decree Divorced Legally Separated Date of separate maintenance agreement 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 If additional space is needed check hereand list on page 3 To be completed by a Certified Volunteer Preparer Name (first, last) Do not enter your Date of Birth Relaionship Number of US name or spouse's name below this Did this Did the Did the Resident Single or Full-time Totally and Is this (mm/ddbyy) to you (for nths Citizen of US, Married as Student Permanently person a person person taxpayer(s) taxpayer(s) example: lived in (yeso) Canada, of 12/31/18 last year Disabled ifying providehave less provide more pay more than son, daughter, last year (yesno) | (yesno) | child/relative | more than of any other | 50% of his/ | of income? | support for | maintaining a person? her own yeso) this person? home for this (yeso)support? your home | than $4,150 | than 50% of | half the cost of or Mexico (S/M) last year none, etc) (yeso/NA) person? SARA CLARK MADISON CLARK 05/06/10 DAUGHTER12 07131/12 DAUGHTER 12 YES YES YES | YES YES YES NO NO Catalog Number 52121E www.irs gov Form 13614-C (Rev. 10-2018) Page 2 Check appropriate box for each question in each section Yes No Unsure Part IIl Income Last Year, Did You (or Your Spouse) Receive K | | | 1 . (B) Wages or Salary? (Form W-2) lf yes, how many jobs did you have last year? 2 | K | | 2, (A) Tip Income? X3. (B) Scholarships? (Forms W-2, 1098-T) | 2 | | 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) X6. (B) Alimony income or separate maintenance payments? || | 7, (A) Self-Employment income? (Form 1099-MISC, cash) X8. (A) Cash/check payments for any work performed not reported on Forms W-2 or 1099? | | || | | | | 9. (A) Income (or loss) from the sale of Stocks, Bonds 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 Com pensation? (Form 1099G) X13. (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, Sch K-1, royalties, foreign income, 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 X2. Contributions to a retirement account? IRA (A) | | | 3, (B) College or post secondary educational expenses for yourself, spouse or dependents? (Form 1098-T) X4. (A) Deductions Medical & Dental (including insurance premiums) 401K (B) Roth IRA (B) Other Mortgage Interest (Form 1098) Charitable Contributions Taxes (State, Real Estate, Personal Property, Sales) | | | 5, (B) Child or dependent care expenses such as daycare? | K | | 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. (HSA) 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) X3. (A) Adopt a child? | k | | 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. (B) Live in an area that was declared a Federal disaster area? If yes, where? X7. (A) Receive the First Time Homebuyers Credit in 2008? | | 8. (B) Make estimated tax payments or apply last year's refund to this year's tax? If so how much? | | | 9, (A) File a federal return last year containing a "capital loss carryover" on Form 1040 Schedule D? | K | | 10. Receive a letter from the IRS? Catalog Number 52121E Form 13614-C (Rev. 10-2018) www.irs.gov Page 3 Check appropriate box for each question in each section Yes No Unsure Part VI Health Care Coverage Last year, did XO1. (B) Have health care coverage? our spouse, or dependent(s) | K | | | | | 2. (B) Receive one or more of these forms? (Check the box) Form 1095-B 3. (A) Have coverage through the Marketplace (Exchange)? [Provide Form 1095-A] Form 1095-C 3a. (A) If yes, were advance credit payments made to help you pay your health care premiums? 3b. (A) If yes, Is everyone listed on your Form 1095-A being claimed on this tax return? X4. (B) Have an exemption granted by the Marketplace? To be Completed by a Certified Volunteer Preparer (Use Publication 4012 and check the appropriate box(es) indicating Minimum Essential Coverage (MEC) for everyone listed on the return.) Name MEC AlI Year No MEC Months with MEC Months with Exemption Exempt All Year Notes Taxpayer Spouse Dependent Dependent Dependent Part VIl 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) JFMAMJJASONDJ F M A M J J A S O N D JFMAMJJASONDJ F M A M J J A S O N D JFMAMJJASONDJ F M A M J J A S O N D JFMAMJJASONDJ F M A M J J A S O N D JFMAMJJASONDJ F M A M J J A S O N D 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 X You Spouse a. Direct deposit b. To purchase U.S. Savings Bonds c. To split your refund between different accounts X Yes No Yes Yes X No 4. If you have a balance due, would you like to make a payment directly from your bank account? Yes 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. 5. 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 6. Would you say you can read a newspaper or book in English? 7. Do you or any member of your household have a disability? 8. Are you or your spouse a Veteran from the U.S. Armed Forces? Additional comments X Very weWell Yes Not wellNot at all Prefer not to answer Prefer not to answer No es x No Prefer not to answer 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:MPT:T SP, 1111 Constitution Ave. NW, Washington, DC 20224 Catalog Number 52121E Form 13614-C (Rev. 10-2018) www.irs.gov