Part II – Marital Status and Household Information

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

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 III – Income – Last Year, Did You (or Your Spouse) Receive

Part IV – Expenses – Last Year, Did You (or Your Spouse) Pay

Part V – Life Events – Last Year, Did You (or Your Spouse)

Part VI - Health Care Coverage - Last year, did you, your spouse, or dependent(s)

Visit http://www.healthcare.gov/ or call 1-800-318-2596 for more information on health insurance options and assistance.

If advance payments of the premium tax credit were paid on your behalf to help pay your health insurance premiums, you should report life changes, such as, income, marital status or family size changes, to your Marketplace. Reporting changes will help to make sure you are getting the proper amount of advance payments.

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.)

Part VII – Additional Information and Questions Related to the Preparation of Your Return

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.

Part VIII - Quality Review Section

• Taxpayer (and Spouse's) identity was verified with a photo ID.
• The volunteer return preparer/quality reviewer are certified to prepare/review this return and return is within scope of the program.
• All questions in Parts I through VI have been answered.
• All unsure boxes were discussed with the taxpayer and correctly marked yes or no.
• The information on pages one through three was correctly addressed and entered on the return.
• Names, SSNs, ITINs, and EINs, were verified and correctly transferred to the return.
• Filing status was verified and correct
• Personal and Dependency Exemptions are entered correctly on the return.
• All Income (including income with or without source documents) checked "yes" in Part III was correctly transferred to the tax return.
• Adjustments to income, such as student loan interest, IRA contributions, self employment tax, were verified and are correct.
• Standard, Additional or Itemized Deductions are correct.
• All credits are correctly reported.
• All applicable provisions of ACA were considered for each person named on the tax return and were entered correctly.
• Any Shared Responsibility Payments are correct.
• Withholding shown on Forms W-2, 1099 and Estimated Tax Payments are correctly reported.
• Direct Deposit/Debit and checking/saving account numbers are correct.
• SIDN is correct on the return.
• The taxpayer(s) was advised that they are responsible for the information on their return.

I understand that the information i have provided on this return is true.If any of this information is incorrect, i understand that a formal letter will be sent bt that bank if
i am denied for RAL; reason for denial: IRS say you owe back taxes, IRS say you have a current garnishment, your tax return meets a certian profile that the bank finds unfavorable, IRS is auditing your EIC, EITC is claimed, and it is for a foster child, dependent different from last year, primary tax payer is less than 18 years old, refund amount minus ETIC is less tah $0, refund amount is gretaer tha $9,999.99, or you have an outstanding debt with the bank that provides the RAL. We don't control over these reasons. I understand also that my refund may be provided in more than one check.

Adopted from IRS FORM-C ( Rev10-2015)