Interview Notes .Emily is single and has two young girls, Sara and Madison, who lived with her all .Emily paid more than half of the support for her daughters and all the cost of keep- . Emily was unemployed for two months (March and April). She cashed in her 401(k) .Emily is paying off a student loan that she took out when she attended college fora . She took some courses this year at Drew Community College to improve her job .Emily and her two daughters, Sara and Madison, had qualified health insurance year. ing up the home. savings and used the money to pay household expenses. few courses in 2015. skills as a health aide. from her employers for 10 months out of the year. They did not have coverage in March and April. Form-13614-C October 2018) Department of the Treasury Internal Revenue Service Intake/Interview & Quality Review Sheet OMB Number 1545-196 Please complete pages 1-3 of this form. You are responsible for the information on your return. Please provide 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.complete and accurate information Picture ID (such as valid driver's license) for you and your s . If you have questions, please ask the IRS-certified volunteer arer 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 EMILY 2. Your spouse's first name M.I. Last name Daytime telephone number Are you a U.S. citizen? YOUR PHONE # CLARK es M.I Last name Daytime telephone number Is your spouse a U.S. citizen? Yes State 3. Mailing address 129 PENNINGTON PLACE 4. Your Date of Birth 04/29/1978 Apt # | City ZIP code YOUR ZIP Yes YOUR CITY 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 No 0 Yes No Yes No 5. Your job title MED ASSISTANT es 7. Your spouse's Date of Birth8. Your spouse's job title a. Full-time student 10. Can anyone claim you or your spouse as a dependent? YesNo 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 X Never Married (This includes registered domestic partnerships, civil unions, or other formal relationships under state law) Yes 0 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 2018Yes No Divorced Date of final decree 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 here and list on page 3 To be completed by a Certified Volunteer Preparer Did this Did this Did the Did the Name (first, last) Do not enter your Date of Birth Relationship Number of US name or spouse's name beloww Resident Single or Full-time Totally and Is this (mm/ddyy) to you (for othsCitizenof US, Married as Student Permanently person a person person taxpayer(s) taxpayer(s) example: lived in (yesno) Canada, of 12/31/18 last year Disabled qualifying provide have less provide more pay more than son, daughter, last year your home or Mexico (S/M) last year (yes/ho) (yeso) (yeso) child/relative more than of any other 50% of his/ person? | her own (yeso) support? | than $4,150 | than 50% of of income? | support for (yesno) | this person? | half the cost of | maintaining a | home for this none, etc) (yeso/wA) person? SARA CLARK MADISON CLARK 05/06/10 DAUGHTER12 07131/12 DAUGHTER 12 YES YES YESYES YES YES NO Catalog Number 52121E 13614-C (Rev. 10-2018) www.irs.gov Form 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 | | | K | | 1. (B) Wages or Salary? (Form W-2) 2, (A) Tip Income? If yes, how many jobs did you have last year? 2 | 3. (B) Scholarships? (Forms W-2, 1098-T) | K | | 4. (B) Interest/Dividends from: checking/savings accounts, bonds, CDs, brokerage? (Forms 1099-INT, 1099-DIV) | | K 11. (A) Retirement income or payments from Pensions. Annuities, and or IRA? (Form 1099-R) | | | 5. (B) Refund of state/local income taxes? (Form 1099-G) 7, (A) Self-Employment income? (Form 1099-MISC, cash) 9. (A) Income (or loss) from the sale of Stocks, Bonds or Real Estate? (including your home) (Forms 1099-S, 1099-B) X 6. (B) Alimony income or separate maintenance payments? | | 2 | 8. (A) Cash/check payments for any work performed not reported on Forms W-2 or 1099? | K | | 10. (B) Disability income? (such as payments from insurance, or workers compensation) (Forms 1099-R, W-2) X12. (B) Unemployment Compensation? (Form 1099G) x13. (B) Social Security or Railroad Retirement Benefits? (Forms SSA-1099, RRB-1099) || | 14. (M) Income (or loss)from Rental Property? || | K | | | | 15. (B) Other income? (gambling, lottery, prizes, awards, jury duty, Sch K-1, royalties, foreign income, etc.) Specify | 1. (B) Alimony or separate maintenance payments? If yes, do you have the recipient's SSN? Yes No | 3, (B) College or post secondary educational expenses for yourself, spouse or dependents? (Form 1098-T) Yes No Unsure Part IV- Expenses-Last Year, Did You (or Your Spouse) Pay X2. Contributions to a retirement account? [ ] IRA (A) 401K (B) Roth IRA (B) Other | | | 4. (A) Deductions: Medical & Dental (including insurance premiums) Taxes (State, Real Estate, Personal Property, Sales) Mortgage Interest (Form 1098) 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.? | K | 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? KI | | 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 you, your spouse, or dependent(s) | | | 1 . (B) Have health care coverage? | K | | 2, (B) Receive one or more of these forms? (Check the box) Form 1095-B Form 1095-C X3. (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? | K | 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 All Year No MEC Months with MEC Months with Exemption Exempt All Year Notes Taxpayer Spouse Dependent Dependent Dependent Part VII 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: a. Direct deposit X You Spouse b. To purchase U.S. Savings Bonds c. To split your refund between different accounts No X Yes No Yes Yes No 4. If you have a balance due, would you like to make a payment directly from your bank account? 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 & speak ng? > 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? Yes X No Very wel Well X No X No well O vel | Not at all Peer otto answer Prefer not to answer very well Not well Not at all Yes Yes Prefer not to answer Prefer not to answer 8. Are you or your spouse a Veteran from the U.S. Armed Forces? 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 5US.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. 10-2018) Visit the IRS website at www.irs.goviele a Employee's social security number accurate, 259-00-XXXX OMB No. 1545-0008 FASTI Use number 1 Wages, tips, other compensation 33,000.00 security wages 33,000.00 2 Federal income tax withheld 2,600.00 2,046.00 479.60 35-600XXXX c Employer's name, address, and ZIP code SALEM RETIREMENT HOME 1270 WEST 29TH STREET YOUR CITY, STATE ZIP 5 Medicare wages and tips 6 Medicare tax withheld 33,000.00 7 Social security tipes 8 Allocated tips d Control number 9 Verification code 10 Dependent care benef ts e Employee's first name and initial Last name Suft. 11 Nonqualified plans 12a See instructions for box 12 DDI 3,800.00 12b EMILY CLARK 129 PENNINGTON PLACE YOUR CITY, STATE ZIP 12c 12d f Employee's address and ZIP code 15 StateEmployer's state ID number 16 State wages, tips, etc. 17 State income tax18 Local wages, tips, etc. 19 Local income tax 20 Locality YS | 35-600xxxx 33,000.00 2,238.00 Wage and Tax Department of the Treasury-Internal Revenue Service 201 LStatement Form Copy B-To Be Filed With Employee's FEDERAL Tax Return. This information is being furnished to the Internal Revenue Service. MB.iles o Safe, accurate, Visit the IRS website at www.irs.gowleile s social security number 259-00-XXXX OMB No. 1545-0008 FASTI Use 2 Federal income tax withhold 350.00 217.00 50.75 39-700XXXX c Employer's name, address, and ZIP code 3,500.00 al security wages 3,500.00 al security tax withheld DAVIDSON INC 4325 NORTHRIDGE AVE YOUR CITY, STATE ZIP 5 Medicare wages and tipe 6 Medicare tax withheld 3,500.00 Social security tips 8 Allocated tips d Control number 9 Venitication code 10 Dependent care benelits e Employee's first name and initial Last name Sutt. 11 Nonqualified plans 12a See instructions for box 12 450.00 EMILY CLARK 129 PENNINGTON PLACE YOUR CITY, STATE ZIP 14 Other 12c 12d f Emplcyee's address and ZiP code 5 State Employer's state ID number YS 39-700xxxx 16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax 20 Localinty 3,500.00 210.00 Wage and Tax 201 Department of the Treasury- Internal Revenue Service LStatement Copy B-To Be Filed With Employee's FEDERAL Tax Return. This information is being furnished to the Internal Revenue Service. CORRECTED (if check 1 Unemployment compensation OMB No. 1545-0120 PAYER'S name, street address, city or town, state or province, country. ZIP or foreign postal code, and telephone no. STATE UNEMPLOYMENT COMMISSION 1000 GOVERNMENT PLAZA YOUR CITY, STATE ZIP (555) 555-4321 PAYER'S TIN $2,200.00 2 State or local income tax 2018 Government refunds, credits, or offsets Payments Fom 1099-G 4 Federal $220.00 6 Taxable grants RECIPIENT'S TIN 3 Box 2 amount is for tax year Copy income tax withheld 35-700XXXX 259-00-XXXX For Recipient This is important tax RECIPIENTS name 5 RTAA payments EMILY CLARK 8 If checked, box 2 is trade or business being furnished to the IRS. If you are required Street address (including apt. no.) 129 PENNINGTON PLACE City or town, state or province, country, and ZIP or foreign postal codeS YOUR CITY, STATE ZIP Account number (see inst negligence penalty or other sanction may be imposed on you if this 9 Market gain 10a State 10b State identfication no 11 State ncome wdincome is taxable and the IRS determines that it has not been Form 1099-G (keep for your records) Department of the Treasury-Internal Revenue Service orm CORRECTED (if check Distributions From Retirement Plans Insurance Contracts, etc. PAYER'S name, street address, city or town, state or province country, and ZIP or foreign postal code OMB No. 1545-0119 2,000.00 2a Taxable amount KENT STATE BANK FOR SALEM RETIREMENT HOME 401 (K) 743 COLQUITT WAY YOUR CITY, STATE ZIP 2,000.00 2b Taxable amount not determined Form 1099-R Copy Report this income on your federal tax return. If this form shows federal income tax withheld in PAYER'S TIN RECIPI 3 Capital gain (included 4 Federal income tax in box 2a withheld 38-200XXXX RECIPIENT'S name 300.00 5 Employee contributions/ 6 Net unrealized 259-00-XXXX appreciation in employer's secunities box 4, attach this copy to your return contributions or EMILY CLARK Street address (including apt. no.) 7 code(s) This information is 129 PENNINGTON PLACE 9b Total employee contributions City or town, state or province, country, and ZIP or foreign postal code 9a YOUR CITY, STATE ZIP 10 Amount allocable to IRR Your percentage of total ion 11 1st ye FATCA desig. Roth contrib. 12 State tax withheld 13 State/Payer's state no. 14 State distribution within Account number (see instructions) 15 Local tax withheld 16 Name of locality 17 Local distribution Form 1099-R Department of the Treasury-Internal Revenue Service orm CORRECTED (if checked OMB No. 1545-1576 RECIPIENT'S/LENDER'S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone number FINANCIAL AID PARTNERS 666 LINCOLN YOUR CITY, STATE ZIP 2018 Student Loan Interest Statement Form 1098-E RECIPIENT'S TIN BORROWER'S TIN 1 Student loan interest received by lender Copy B 38-900XXXX BORROWER'S name 259-00-XXXX For Borrower This is important tax you are required to file a 600.00 information and is EMILY CLARK fumished to the IRS. Street address (including apt. no.) retum, a negligence or 129 PENNINGTON PLACE City or town, state or province, country, and ZIP or foreign postal code YOUR CITY, STATE ZIP Account number (see instructions) IRS determines that an underpayment of tax results because you overstated a deduction for student loan interest. 2 If checked, box 1 does not include loan origination fees and/or capitalized interest for loans made before tember 1, 2004 www.irs.gov/Form1098E Fom 1098-E (keep for your records) Department of the Treasury-Internal Revenue Service CORRECTED FILER'S name, street address, city or town, state or province, country, ZIP or 1 Payments received for foreign postal code, and telephone number OMB No. 1545-1574 qualified tuition and related DREW COLLEGE 1000 COLLEGE AVE YOUR CITY, STATE ZIP 2800.00 2018 Tuition Statement Form 1098-T FILER'S employer identification no. STUDENT'S TIN 3 If this box is checked, your educational institution changed Copy its reporting method for 2018 35-500XXXX STUDENT'S name 259-00-XXXX For Student 4 Adjustments made for a 5 Scholarships or grants This is important tax information and is being furnished to the IRS. This form must be used to complete Form 8863 to claim education credits. Give it to the tax preparer or use it to prepare the tax return. prior year EMILY CLARK Street address (including apt. no.) City or town, state or province, country, and ZIP or foreign postal code Service Provider/Acct. No. (see instr.) 6 Adjustments to 7 Checked if the amount scholarships or grants for a prior year in box 1 includes amounts for an 129 PENNINGTON PLACE IC YOUR CITY, STATE ZIP beginning January March 2019 8 Check if at least 9 Checked if a graduate 10 Ins. contract reimb/refund half-time student student Fom 1098-T (keep for your records) www.irs.gov/Form1098T Department of the Treasury-Internal Revenue Service 303 Twiggs Trail Your City, Your State Your Zip (555) 555-1234 River's Child Care December 31, 2018 Received from Emily Clark: $1,500 for after-school care for Sara Clark $1,500 for after-school care for Madison Clark $3,000 Total amount received for child care in 2018 Ellen River EIN: 35-900xxxx 1234 Emily Clark 129 Pennington Place Your City, State 00000 20 PAY TO THE ORDER OF DOLLARS Adelphi Bank and Trust Anytown, State 00000 For : 111000025 123456789 1 234 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