Form-13614-C Octobor 2018) Department of the Treasury-Internal Revenue Service OMB Numbor 1545-1964 Intake/lnterview & 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 preparer You will need . Tax Information such as Forms W-2, 1099, 1098, 1095. : Pcture D (stgh ar valid driver's license) roryou an your spxusturn fyou ntvenquestionas phease ask the IRS-certiied 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 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 MI. Last name Daytime telephone number Is your spouse a U.S. citizen? es 3. Mailing address 129 PENNINGTON PLACE 4. Your Date of Birth 04/29/1978 Apt # City State ZIP code YOUR CITY YOUR ZIP 5. Your job title MED ASSISTANT 6. Last year, were you: b. Totally and permanently disabled Yes 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 Yes No Yes No Yes No 7. Your spouse's Date of Birth 8. Your spouse's job title a. Full-time student 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? 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) Yes No 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 YesNo Divorced Legally Separated Date of separate maintenance agreement Widowed Date of final decree 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 here and list on page 3 To be completed by a Certified Volunteer Preparer Name (frst, las) Do not enter your Date of Birth Relationship Number o US name or spouse's name below ResidentSingle or Full-time Totally and Is this Did this Did this Did the Did the (mmddvy)to you (formonths Ctizen of US, Married as Student Permanently person aperson person taxpayer(s) taxpeyers) example: ived in yesno Canada of 12/31/18 last year Disabled qualifying provide have less provide more pay more than son daughler, last year parent (yes no) (yesmo) cria relative I more than of any other 50% of his/ lor income? Support for |maintaining a person? her own (eso) this person? home for this (yeso) support? your home | than S4.150| than 50% of | half the cost of or Mexico | (S last year yesno) (yeso wA) person? la) sino SARA CLARK MADISON CLARK 05/06/10 DAUGHTER12 07131/12 DAUGHTER 12 YES YES YES YES YES YES NO NO Catalog Number 52121E www.rs.gow Form 13614-C (Rev. 10-2018) Page 2 Check appropriate box for each question in each section Yes No Unsure Part Income Last Year, Did You (or Your Spouse) Receive ] | 8 | | | 1. (B) Wages or Salary? (Form W-2) 2 . (A) Tip Income? lf yes, how many jobs did you have last year? 2 | X3. (B) Scholarships? (Forms W-2, 1098-T) | K | | | | | 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 10993) X6. (B) Alimony income or separate maintenance payments? X7. (A) Self-Employment income? (Form 1099-MISC, cash) || 29 | | 8. (A) Cash/check payments for any work perommed 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) D | ] | KO12. (B) Unemployment Compensation? (Form 1099G) 13. (B) Social Security or Railroad Retirement Benefits? (Forms SSA-1099, RRB-1099) D || | 14 (M) Income (or loss)from Rental Property? g | | 15 ( B) Other income? (gambling, lottery, przes, 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 a | 2. Contributions to a retirement account? || | 3 . (B) College or post secondary educational expenses for yourself, spouse or dependents? (Form 1098-T) | | 4. (A) Deductions: Medical & Dental (including insurance premiums) IRA (A) 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? | 6. (B) For supplies used as an eligible educator such as a teacher, teacher's aide, counselor, etc.? 7. (A) Expenses related to selt-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 canceled/forgiven by a lender or have a home foreclosure? (Forms 1099-C, 1099-A) X 3. (A) Adopt a child? | K. | | 4. (B) Have Earned income Credit, Child Tax Credit or American Opportunity Credit disallowed n a prior 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? If yes, for which tax year? 7. (A) Receive the First Time Homebuyers Credit in 2008? >a | | 8, (B) Make estimated tax payments or apply last year's refund to this year's tax? If so how much? X9. (A) File a federal return last year containing a "capital loss carryover' on Form 1040 Schedule D? | | | 10 Receive a letter from the RS? Catalog Number 52121E www.irs.gov Form 13614-C (Rev. 10-2018) Pagc 3 Check appropriate box for each question in each section Yes No Unsure Part VI Health Care Coverage Last year, did you, your spouse, or dependent(s) X1. (B) Have health care coverage? | | 2 . (B) Receive one or more of these forms? (Check the box) Form 1095-B Form 1095-C | | 3, (A) Have coverage through the Marketplace (Exchange)? [Provide Form 1095-A] 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? 0 4. (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 AI Year No MEC Months with MEC Months with Exemption Exempt All Year Notes Taxpayer Spouse 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 JASOND JFMAMJJASONDJ F M A M J J A S O N D JFMAMJJASONDJ F M A M J J A S O N D Dependent Dependent Part VII- Additional Information and Questions Related to the Preparation of Your Return 1. Provide an email address (optional) (this emai address will not be used for contacts from the Internal Revenue Service) 2. Presidential Election Campaign Fund (lf you check a box, your tax or refund will not change) Check here if you, or your spouse if filing jcintly, want $3 to go to this fund 3. If you are due a refund, would you ike ou Spouse a. Direct deposit b. To purchase U.S. Savings Bonds c. To split your refund between different accounts Yes No No Yes X No es 4. If you have a balance due, wou d you like to make a payment directly from your bank account? Yes Many free tax preparation sites operate by receiving grant money. The data from the following questions may be used by this site to apply for these grants. Your answers will be used only for statistical purposes. 5, would you say you can carry on a conversation in English, both understanding & speaking?very well Well Not well Not at all Prefer not to answer 6. Would you say you can read a newspaper or bcok in English? 7. Do you or any member of your household have a disability? 8. Are you or your spouse a Veteran from the U.S. Armed Forces? Additional comments No very well Prefer not to answer [] Wel X No X No Not well Not at all Yes Prefer not to answer es Prefer not to answer Privacy Act and Paperwork Reduction Act Notice The Privaoy Act of 1074 requires that when we ask for information wc tel you our legal right to ask for the informaton, why wo ore acking for it and how it will bo uscd. We must also tell you what could happon if wo do not recove it, and whether your response s voluntary requred to obtain a benefit or mandatory Our legal nght to ask for informaSon i$ 5 USC. 301. We are asking for this information to assist u$ contacting you relative to your ir terest and or participation in the IRS volunteer income tax pre arason and outreach pro rams. The information ou provide ma be urn s d to others wr coordinate activities and sta ng at volunteer return preparation sites or outreach activities. The information may also be used to establish effective controis, send correspondence and recognize volunteers. Your response is oluntary. However, if you do not pro de the requested inkmmaton,e RS may not be able to use your ass stance n these programs The Paperwork Reduct on Act requres that the RS dispay an MB ntrol number or all publc information requests. The OMB Control Number for this study is 1545-1964, Also, if you have any comments regerding the tme estimates associated with this study or suggestion on making this process simpler please write to the internal Revenue Servico, Tax Products Coordinating Comminoo, SE W CAR MP TT SP, 1111 Constitution Ave. NW, Washington, DC 20224 Catalog Number 52121E www.irs.gov Form 13614-C (Rev. 10-2018) Visit the IRS website at www.is.goviafle a Employee's social security number Safe, accurate, 259-00-XXXX OME No. 1545-C008 FASTI Use b Employer icentification number (EIN) 1 Wages, 5ps, oher compensaton 33,000.00 al security wages 33,000.00 2 Federal income tax withhec 2,600.00 4 Social security tax wahhald 2,046.00 35-600xXxx c Employer's name, address, and ZIP eode SALEM RETIREMENT HOME 1270 WEST 29TH STREET YOUR CITY, STATE ZIP 5 Medcare wages and sps 6 Medcare tax withneld 33,000.00 479.60 7 Social security tipe d Control number 10 Depensent care benetits Employee'g first name and intial L namo St 11 Nonqualmed plans 12a Sao instnuctions tor pox 12 DDI 3,800.00 EMILY CLARK 129 PENNINGTON PLACE YOUR CITY, STATE ZIP 14 Cther 12c 120 f Employee's acdress and ZIP coce 15 3e Employer's state ID number 16 Stste wages, tips, et 17 State ncome tax 18 Local wages, tios, etc.19 Loca income tax 20 Locality YS 35-600xXXX 33,000.00 2,238.00 2018 Wage and Tax Department the Treasry-int Revenue Servce % Statement Form Copy B-To Bo Filod With Employoo's FEDERAL Tax Roturn. This intormation is being furnished to the Internal Revenue Service. visit the IRS website at yee's social security number 259-00-XXXX Safe, accurate, OMB No. 154-08 FASTI Uco www.is.gowicflo b Empbyer icentificarion number (EIN) 1 Wages, ips, other compensaton 2 Foderal income tox withhed 3,500.00 3,500.00 3,500.00 350.00 security tax wihhald 217.00 39-700XXXX Employer's name, address, ZIP code c al security wages DAVIDSON INC 4325 NORTHRIDGE AVE YOUR CITY, STATE ZIP 5 Medicare wages and ips 6 Medicare tax withheld 50.75 7 Social security tips 8 Allocated tips d Control numbar 10 Dependent care benetits o Empoyce'e tirst name and intiai Laet nama St 11 Nonqualited plane 450.00 EMILY CLARK 129 PENNINGTON PLACE YOUR CITY, STATE ZIP 12c f Employee's acdress and ZIP coce 15 Se Employer's state D number 16 Stste wages, Sps, et 17 State income tax 18 Local wages, tios etc. 19 Local income tax 20 Locality YS 39-700XXXX 3,500.00 210.00 2010 Wage and Tax Department of the Treasry-Intenal Revenue Service LStatement Form Copy B-To Bo Filod With Employoo's FEDERAL Tax Roturn. This intcrmaticn is being furnished to the internal Revenue Service Basic Scenario 8: Test Questions 20. Does Emily have to pay a shared responsibility payment on her tax return? a. Yes, she did not have full health coverage for 12 months of the year. b. No, she can claim a short coverage gap exemption on her tax return. 21. The amount of Emily's education credit claimed on her tax return is $ 22. Emily's total federal income tax withheld is $ 23. What is the total credit amount shown on Form 2441, Child and Dependent Care Expenses? a. $0 b. $600 c. $660 d. $792 24. Emily is eligible to claim the child tax credit on her 2018 tax return. a. True b. False 25, Emily is subject to the 10% additional tax from her 401(k) distribution. a. True b. False