Form 13614 

Rev. August 2006 

Department of the Treasury – Internal Revenue Service 

Intake and Interview Sheet OMB # 1545-1964 

You (and Spouse) will need: 

• Proof of Identity 

• Copies of ALL W-2, 1098, 1099 forms 

• Social Security (SSN) or Individual Tax 

Identification Number (ITIN) for all 

individuals to be listed on the return 

• Child care providers’ identification number 

• Taxpayers’ banking information (voided check 

and/or savings deposit slip) for refund deposits 

• Estimated tax payments made, etc. 

• Amounts of other income 

Part I: Taxpayer Information 

1. Your First Name M.I. Last Name 2. SSN or ITIN 

3. Date of Birth (mm/dd/yyyy) 4. Job Title 

5. Spouse’s First Name M.I. Last Name 6. SSN or ITIN 

7. Date of Birth (mm/dd/yyyy) 8. Job Title 

9. Address Apt # City State Zip Code 

10. Phone Numbers: Daytime Evening Cell 

11. Are you a U.S. Citizen? Yes No 12. Is your Spouse a U.S. Citizen? Yes No 

13. Can your parents or someone else claim you or your spouse as a dependent on their tax return? Yes No 

14. Did you pay more than half the cost of keeping up the home? Yes No 

15. Check if Legally Blind: Taxpayer Spouse 

16. Check if Permanently and Totally Disabled: Taxpayer Spouse 

17. On December 31st 2006: 

Were you: Single Legally Married Separated Divorced 

a. If married, were you living apart from your spouse during the last 6 months of the year? Yes No 

18. Was your spouse deceased? If yes, provide the date of death. (mm/dd/yyyy) 

Part II. Family and Dependent Information – Do not include you or your spouse. 

Print the name of everyone who lived in your home and outside your home that you supported during the year. 

(a) 

Name 

(b) 

Date of Birth 

mm/dd/yyyy 

(c) 

Social Security 

Number or ITIN 

(d) 

Relationship 

(son, daughter, etc.) 

(e) 

Months person 

lived with you in 

2006 

(f) 

US Citizen, 

Resident of US, 

Canada or 

Mexico? 

(g) 

Is the dependent 

a full time student? 

(yes or no) 

Catalog Number 38836A Form 13614 (Rev. 8-2006) 

STOP Page 2 TO BE COMPLETED BY CERTIFIED VOLUNTEER 

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 suggestions 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. 
Part Ill. Filing Status & Dependency Determination 

Volunteers: In order to conduct a thorough interview, please use the decision trees, interview tips and informational charts in 

Publications 4012 and/or 17 in addition to this intake sheet. This intake sheet does not constitute a complete interview. 

Filing Status Determination – Use Publications 4012 and/or 17 to determine filing status. 

1. Based on the interview, the filing status of the taxpayer is: Single MFJ MFS* HH Qualifying 

Widow(er) 

*Spouse Name Social Security Number 

Dependency Determination – Use Publications 4012 and/or 17 to determine dependency exemptions. 

Yes No 2. Did the taxpayer provide more than 50% of the support for the dependents claimed?

3. Is there a signed Form 8332 or a divorce decree that allows someone else to claim 

the dependent(s)? 

Yes No 

Yes No 4. Is the dependent permanently and totally disabled?

5. Based on the interview, how many individuals qualify as dependents for this return? 

COMMONLY USED INCOME AND EXPENSES 

Volunteers: Please use Publication 17, Your Federal Income Tax for Individuals and Publication 4012, 

Volunteer Resource Guide while discussing the questions below with the taxpayer. 

Part IV. Income – In 2006, did you receive: 

Yes No 1. Wages or Salary (Include W-2s for all jobs worked during the year)

Yes No 2. Disability income

Yes No 3. Interest from: checking or savings account, bonds, dividends, CD, or brokerage account

Yes No 4. State tax refund (may be taxable if you itemized last year)

Yes No 5. Alimony income

Yes No 6. Tip income

Yes No 7. Pension and/or IRA distribution

Yes No 8. Unemployment

Yes No 9. Social Security or Railroad Retirement

Yes No 10. Self Employment

Yes No 11. Other Income such as gambling winnings, awards, prizes and Jury duty

Part V. Adjustment – Did you have 2006 expenses for: 

Yes No 1. IRA or other retirement account

Yes No 2. Alimony payments paid (If yes, you must provide the name and SSN of the recipient)

Yes No 3. Education related expenses

Part VI. Itemized Deductions – Did you have 2006 expenses for: 

Yes No 1. Un-reimbursed medical expenses

Yes No 2. Home mortgage payments (interest and taxes – see Form 1098)

Yes No 3. Charitable contributions

Part VII. Credits – In 2006, did you have: 

Yes No 1. Child/dependent care expenses that allow you (and your spouse-if MFJ) to work

Yes No 2. Educational expenses for you or your dependents

Yes No 3. Retirement Savings Contribution

Part VIII. Earned Income Tax Credit Determination – EITC Eligibility 

Yes No 1. Was EITC previously disallowed (if yes taxpayer may not be eligible for EITC)

Yes No 2. Based on the interview, is the taxpayer qualified for EITC?

Catalog Number 38836A Form 13614 (Rev. 8-2006) 

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