Intake, Interview and Quality Review Sheet

A complete taxpayer intake sheet for free tax preparation sites, covering personal and household details, sources of income, expenses, life events and refund preferences. Certified volunteers work through it with the taxpayer before the return is prepared and reviewed.

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Part I – Your personal information

1. Your first name

Middle initial

Last name

Daytime telephone number

Are you a U.S. citizen?

Yes No

2. Your spouse's first name

Spouse's middle initial

Spouse's last name

Spouse's daytime telephone number

Is your spouse a U.S. citizen?

Yes No

3. Mailing address

Apartment number

City

State

ZIP code

4. Your date of birth

5. Your job title

6. Check all that apply to you

a. Full-time student

Yes No

b. Totally and permanently disabled

Yes No

c. Legally blind

Yes No

7. Your spouse's date of birth

8. Your spouse's job title

9. Check all that apply to your spouse

a. Full-time student

Yes No

b. Totally and permanently disabled

Yes No

c. Legally blind

Yes No

10. Can anyone claim you or your spouse as a dependent?

Yes No Not sure

11. Have you, your spouse or your dependents suffered tax-related identity theft or received an Identity Protection PIN?

Yes No Not sure

1. As of December 31, 2020, what was your marital status?

Answer only if you were married or separated during the year

a. If married, did you get married in 2020?

Yes No

b. Did you live with your spouse at any point in the last six months of 2020?

Yes No

Date of the final divorce decree

Date of the separate maintenance decree

Year of the spouse's death

If additional space is needed

I will attach an additional sheet No extra space needed

1. (B) Wages or salary (Form W-2)? If yes, how many jobs did you have last year?

15. (B) Other income (gambling, lottery, prizes, jury duty, virtual currency, Sch K-1, royalties, foreign income)? Please specify

1. (B) Alimony or separate maintenance payments? If yes, do you have the recipient's social security number?

Yes No Not sure

2. If you contributed to a retirement account, select the type of account

Traditional IRA Roth IRA 401(k) plan 403(b) plan SEP IRA Another retirement account

4. Do you have any of the following?

Health savings account Itemised deductions Student loan interest Charitable contributions None of these

4. (B) Was your Earned Income Credit, Child Tax Credit or American Opportunity Credit disallowed in a prior year? If yes, which tax year?

7. (B) Did you make estimated tax payments or apply last year's refund to this year? If so, how much?

1. Email address (optional; it will not be used for contact by the Internal Revenue Service)

2. Presidential Election Campaign Fund: tick if you want $3 to go to this fund (your tax or refund does not change)

Taxpayer only Spouse only Both Neither

Part VII – Refund and payment preferences

Direct deposit

Direct deposit to my account Paper cheque No refund expected

b. To purchase U.S. savings bonds

Yes No

c. To split your refund between different accounts

Yes No

4. If you have a balance due, would you like to pay directly from your bank account?

Yes No

5. Did you live in an area declared a federal disaster area?

Yes No

5. If yes, where?

6. Did you or your spouse receive a letter from the IRS?

Yes No

If you received an IRS letter, bring it to your appointment

7. Can you carry on a conversation in English, both understanding and speaking?

Very well Well Not well Not at all

8. Can you read a newspaper or a book in English?

Very well Well Not well Not at all

9. Do you or any member of your household have a disability?

Yes No Prefer not to answer

10. Are you or your spouse a veteran of the U.S. Armed Forces?

Yes No Prefer not to answer

11. Your race

American Indian or Alaska Native Asian Black or African American Native Hawaiian or Pacific Islander White Prefer not to answer

12. Your spouse's race

American Indian or Alaska Native Asian Black or African American Native Hawaiian or Pacific Islander White Prefer not to answer

13. Your ethnicity

Hispanic or Latino Not Hispanic or Latino Prefer not to answer

14. Your spouse's ethnicity

Hispanic or Latino Not Hispanic or Latino Prefer not to answer

Additional comments

Consent to disclose your tax return information

Consent to use your tax return information

Electronic signature authorisation

Taxpayer declaration of accuracy

Taxpayer signatures

Primary taxpayer printed name

Primary taxpayer signature

Sign here

Date

Secondary taxpayer printed name

Secondary taxpayer signature

Sign here

Date

Section reserved for the certified volunteer

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