Department of the Treasury – Internal Revenue Service 

Volunteer Return Preparation Program Hurricanes 

Katrina, Rita and Wilma Intake/Interview Sheet

Form 13614K

(February 2006) OMB # 1545-1999

Part I All Taxpayers Assisted

Instructions: This section will capture data to properly determine if an individual qualifies for any Hurricane Katrina, Rita 

or Wilma tax benefits. It should be used by screeners, preparers, or others involved in the Volunteer Return Preparation 

Program (VRPP) for all taxpayers assisted. Use with Form 13614, Interview and Intake Sheet.

1. HOUSING DISPLACED INDIVIDUALS YES NO N/A COMMENTS

Did you house a Katrina displaced individual in your home in 2005?

If yes, enter number of days in comments. 1A

1B Was the displaced individual your dependent or spouse?

2. GIFTS TO CHARITY

Did you make any cash charitable contributions between August 

28, 2005 and December 31, 2005? 2A

2B Do you have Katrina related charitable mileage?

2C If yes, do you have written records?

Were you impacted by Hurricanes Katrina, Rita or Wilma? 

(If yes, complete Part II of this form. If no, the form is complete.) 4A

Part II Hurricanes Katrina, Rita, and Wilma Impacted Individuals Only

Instructions: This section is designed to capture critical data to properly prepare tax returns for Hurricane Katrina, Rita, 

or Wilma impacted individuals only. It should be used by screeners, preparers, or others involved in the return 

preparation process to quickly determine if a volunteer can assist the taxpayer or needs to refer them to a Taxpayer 

Assistance Center (TAC), paid professional preparer, or other organizations, if available, trained to prepare casualty loss 

tax returns. If the taxpayer is referred for assistance, Form 13614K should be returned to the taxpayer. 

1. CORE DISASTER AREA

1A What State?

1B What County/Parish?

2. RECORDS/INCOME

2A Do you have a copy of your 2004 Federal Income Tax Return?

2B Do you have your 2005 income and expenses? i.e., W-2, 1099, 1098

(If no to Q, 2A or 2B, see Tax Record Reconstruction on reverse.)

3A

Did you receive a distribution from a qualified retirement plan, 

tax sheltered annuity or IRA in 2005? 4A

5A Did you experience a loss of personal or real property?

5B Did you receive any reimbursements?

Was the reimbursement greater than the property value? 

(If yes, the VRPP site may be able to prepare the tax return.) 

(If no, give the taxpayer this intake sheet and refer them to the 

Casualty Loss Information on reverse.)

5C

Catalog Number 47919C Form 13614K (2-2006)

YES NO N/A COMMENTS

4. HURRICANE KATRINA, RITA, OR WILMA IMPACTED

Was your 2004 earned income greater than your 2005 earned 

income?

3. HOPE AND LIFETIME LEARNING CREDIT

Were you, your spouse, or your dependent enrolled and paying 

tuition at an eligible educational institution located in the Gulf 

Opportunity Zone? 

3A

3. EARNED INCOME CREDIT AND ADDITIONAL CHILD TAX CREDIT

4. RETIREMENT PLAN WITHDRAWALS

5. PROPERTY
CASUALTY LOSS

Volunteers are not trained to prepare Casualty Loss Tax Returns

If you are able to provide any of the following information, it will assist the referred preparer in calculating your casualty loss: 

(Publication 2194, Disaster Losses Kit for Individuals, will assist you in compiling these items.)

If you previously elected the standard deduction and will now be using a Schedule A to itemize your deductions to claim a 

casualty loss, you will also need copies of your prior state tax withholdings, real and personal property taxes, home mortgage 

interest and charitable contributions.

TAX RECORD RECONSTRUCTION

If you do not have a W-2 from each of your employers do the following:

Your employer’s name and complete address, including zip code, employer identification number (if

known - see prior year’s Form W-2 if you worked for the same employer), and telephone number,

Your name, address, including zip code, social security number, and telephone number; and

An estimate of the wages you earned, the federal income tax withheld, and the period you worked for

For a Form 4852, Substitute W-2, call 1-866-562-5227 or visit www.irs.gov.

If you need information from your Prior Federal Tax Return:

For proper identification you will be required to give your name, filing status, social security number,

address and two random answers concerning your status.

If you are not where the fax machine is located, a transcript of your tax return can be mailed to you if

you provide your current address.

c.

An alternative to options 1 and 2 above: You may go to the closest IRS Tax Assistance Center to receive a transcript of 

your prior year tax return and income information.

For IRS Taxpayer Assistance Center locations: Toll-Free 1-866-562-5227 

Web page – www.irs.qov/localcontacts/index.html

For assistance with Reconstructinq Bank Records:

Mississippi Department of Banking: For assistance with State Tax Returns:

Toll-Free Nationwide 1-800-844-2499

State of Louisiana-Department of Revenue: 

1-225-219-731 8 or 1-225-219-0102 Louisiana Office of Financial Institutions:

Toll-Free Nationwide 1-866-783-5530 or In-State 

1- 866-525-9414 Mississippi State Tax Commission:

Web Page – www.ofi.louisiana.gov 1-601-923-7000

Web Page – www.mstc.state.ms.us State of Alabama Banking Department:

1-334-242-3452

Web Page – www.bank.state.al.us

Savings Institutions- Office of Thrift Supervision:

Toll-Free Nationwide 1-800-842-6929

Web Page – www.ots.treas.qov

Catalog Number 47919C Form 13614K (2-2006)

Complete list of personal and non-real estate items lost in the disaster.

Copies of your Federal tax returns for the last three years, if available.

If you claimed a casualty loss on your last year’s return or any prior year return, a copy of the amended returns or any

other documentation, if available.

Insurance reimbursement documentation, if applicable. 

All types of Federal Emergency Management Agency’s (FEMA) reimbursement documentation, if applicable. 

The fair market value of your home, real estate and other personal property before the casualty. 

Any contractor estimates and repairs or replacement costs to damaged property.

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1. Contact your employer for the W-2. 

If you were unable to contact your employer you should complete a Form 4852, substitute W-2. Katrina, Rita, 

or Wilma impacted individuals are not required to wait until February 15th. You will need the following:

that employer. The estimate should be based on year-to-date information from your final pay stub or

leave-and-earnings statement, if available.

2.

3.

Hurricane Katrina displaced individuals may call 1-866-562-5227 to receive a transcript of their tax year 2004

Tax Return via fax. You must remain on the line while the fax is being sent and be in the same location as the 

fax machine.

1.

OR, File Form 4506, Request for Copy of Tax Return, for an actual copy of return filed. Write “Hurricane Katrina, 

Rita, or Wilma” in red letters across the top of the form to expedite processing. The normal processing fee will be 

waived.

2.

If unable to get a transcript by phone, you can file Form 4506 -T, Request for Transcript of Tax Return, 

to request transcript of your previous year’s tax return. Write “Hurricane Katrina, Rita, or Wilma” in 

red letters across the top of the form to expedite processing.

Web Page – www.dbof.state.ms.us

Web page – www.rev.state.Ia.us

Alabama Department of Revenue

1-334-242-1099

Web Page – www.ador.state.al.us

a.

b.

c.

a.

b.