Form PUBLICATION 3319 PUBLICATION 3319 LITC - Low-Income Taxpayer Clinic

LITC
Low Income Taxpayer Clinic

> Access to Representation

P ac k a g e a n d G u id e l i n e s

L ow Income Taxpayer Clinics ensure the
fairness and integrity of the tax system
by educating low income taxpayers
about their rights and responsibilities,
by providing pro bono representation to
taxpayers in tax disputes with the IRS,
by conducting outreach and education to
taxpayers who speak English as a second
language, and by identifying and advocating
for issues that impact low income taxpayers.

20 1 0 GRANT AP PL IC ATION

> Outreach and Education for Taxpayers
Who Speak English as a Second Language

Publication 3319 (05-2009) Catalog Number 26939S Department of the Treasury Internal Revenue Service www.irs.gov

TABLE OF CONTENTS
I Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
II LITC Program Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
III Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
IV LITC Program Grant Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

A Eligibility Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

1 In General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 Controversy Clinic Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
3 ESL Clinic Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
4 Matching Funds Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

B  Office of Management and Budget (OMB) Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

C Audit Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

D Civil Rights Reporting Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

E Lobbying Restrictions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

F Trafficking Victims Protection Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

G Other Applicable Laws and Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

H LITC Grant Agreement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

I Operational Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1 Standards of Operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 Managing Funds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
3 Grantee Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

J Reporting Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1 Interim Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 Year-End Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
V LITC Program Office . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

A Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

B Site Assistance Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

TABLE OF CONTENTS
VI Completion and Submission of Grant Application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

A Where and When to File . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

B LITC Program Grant Application Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

C Submission of Grant Application Packages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

VII Selection and Award of Grant Recipients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

A Eligibility Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

B Evaluation Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1 Technical Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 Program Office Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

C Notification of Award Decisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Appendix A
LITC Program Grant Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Appendix B
LITC Program Grant Application Checklists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
LITC Program Report Package Submission Checklists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Appendix C
Interim and Year-End Report Form and Instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Supplemental Issue Form and Instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Paperwork Reduction Act Notice:

This application package is provided for awards under the Low Income Taxpayer Clinic Grant Program. The
information is requested from the applicants in order to determine their eligibility for an LITC grant and evaluate their
grant proposals. Applicants are not required to respond to this collection of information unless it displays a currently
valid OMB number. The estimated average burden associated with this collection of information is 60 hours per
respondent for program sponsors and 2 hours for student and program participants. Comments concerning the
accuracy of this burden estimate and suggestions for reducing this burden should be directed to the IRS, Tax
Products Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW, IR-6526, Washington, DC
20224. Do not send grant application forms to this address. Grant applications should be sent to: Internal Revenue
Service, Taxpayer Advocate Service, LITC Program Office, TA:LITC, Room 1034, 1111 Constitution Ave., NW,
Washington, DC 20224.

Catalog of Federal Domestic Assistance Number: 21.008 OMB Approval No. 1545-1648

2

LOW INCOME TAXPAYER CLINIC

3

APRIL 2010
Dear Prospective Low Income Taxpayer Clinic Grant Applicant:
I am pleased to announce the opening of the 2011 Low Income Taxpayer Clinic (LITC) grant application period,
which runs through June 15, 2010. The Taxpayer Advocate Service (TAS) is committed to enhancing the LITC Program’s quality and coverage.
The LITC Program Office has adopted a mission statement for the LITC Program. The mission statement centers around
four goals, which apply to some or all of the clinics, depending on the type of services provided. The Interim and YearEnd reports will require clinics to report on how they are achieving those goals. To facilitate reporting of the success and
achievements of each clinic, the LITC Program Office, in conjunction with volunteers from various clinics, is developing
performance measures. These measures will provide a basis for clinics in preparing the required Interim and Year-End
reports. The LITC Program Office will publish the performance measures prior to the beginning of the 2011 grant cycle.
The LITC Program Office assists clinics in meeting program responsibilities, and encourages clinics to voice their concerns
about difficulties they have in meeting program requirements. With advice from the clinics, the LITC Program Office revised
the 2011 Grant Application to make it easier to understand and complete. Some of the specific improvements include:

4

Revising the Interim and Year-End Report Forms to help clinics better capture the nature of their work; and

4

Adding instructions for completing Standard Forms 424 and 425 to address questions received by the
Program Office this past year.

We are pleased that we have funded at least one clinic in all 50 states, the District of Columbia and Puerto Rico during the
2010 grant cycle. The Taxpayer Advocate Service remains committed to achieving maximum access to representation for
low income taxpayers under the terms of this grant program. Thus, in awarding 2011 LITC grants, we will continue to
work toward the following program goals:

4

Ensuring that each state (plus the District of Columbia and Puerto Rico) continues to be served by at least one clinic.

4

Ensuring grant recipients demonstrate that they are serving geographic areas that have sizable populations

4

eligible for and requiring LITC services.
E xpanding coverage in geographic areas that do not have both controversy representation and ESL education and outreach.
To better identify areas most in need of LITC services, the Program Office has completed an evaluation of areas serviced.
Based on the findings of this assessment, the LITC Program Office is accepting applications for the 2011 grant cycle,
with an emphasis on the following types of organizations: (1) organizations currently receiving a grant for the 2010
grant cycle, and (2) organizations not currently receiving a grant for the 2010 grant cycle in the following counties:

Admissible Areas for New Clinic Applications
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CO
CT
FL

4

County
Kern
Stanislaus
Ventura
San Bernardino
Riverside
Placer
Sacramento
Santa Clara
San Joaquin
El Paso
Fairfield
Lee

State
NC
NC
NY
OH
OH
OH
OH
PA
PA
PA
PA
PA

LOW INCOME TAXPAYER CLINIC

County
Guilford
Wake
Orange
Summit
Montgomery
Mahoning
Trumbull
Mercer
Lehigh
Northampton
Dauphin
Cumberland

State
FL
FL
FL
FL
FL

County
Volusia
Polk
Orange
Brevard
Manatee

State
PA
PA
SC
TN
TX

County
Lackawanna
Luzerne
Charleston
Hamilton
Travis

GA-SC Augusta- .
Richmond

TX

Williamson

IL
MA

St. Clair
Worcester

TX
UT

Hidalgo
Weber

MI

Kent

VA

City of .
Virginia Beach

MO

St. Louis

WI

Dane

The LITC Program Office may award grants to qualifying organizations to fund one-year, two-year or three-year project
periods. Any clinic currently receiving an LITC grant that does not expect to use all of its funds must contact the LITC
Program Office immediately so that other clinics and taxpayers may benefit from those funds. Moreover, any clinic
currently receiving a grant that does not intend to reapply for a 2011 grant should notify the LITC Program Office immediately so that we can solicit coverage of that service area by other applicants.
This package contains the current program guidelines, eligibility criteria, application materials, and instructions
on how to file an application. The cost of preparing and submitting an application are the responsibility of each
applicant.
The LITC Program Office will notify each applicant whether they are awarded a grant no later than November 27, 2010.
An organization awarded a grant for providing controversy services must have at least 90 percent of the taxpayers represented or referred with incomes that do not exceed 250 percent of the Federal Poverty Guidelines. At the time this
package was printed, the Department of Health and Human Services had not updated the Federal Poverty Guidelines
and the 2009 Guidelines remained in effect; therefore, in determining whether taxpayers are eligible for LITC assistance, please refer to http://aspe.hhs.gov/poverty/index.shtml for any updates.
If you have questions about the LITC Program or grant application process, please contact the LITC Program Office at
202-622-4711 or by e-mail at [email protected].
I appreciate your interest in the LITC Program and look forward to working with the 2011 Low Income Taxpayer
Clinic grantees to improve the fairness and quality of federal tax administration.

Sincerely,

Nina E. Olson

National Taxpayer Advocate

5

I

INTRODUCTION
This publication outlines requirements for the operation of a qualifying Internal Revenue Service (IRS) Low In-

come Taxpayer Clinic (LITC) program and provides instructions on how to apply for a matching grant under Internal
Revenue Code (IRC) § 7526. All applications for this grant must be completed thoroughly and accurately. Failure to
do so may result in the application not being considered for a grant.
This publication and copies of the required forms and assurances should be retained for future reference. Interim and
Year-End reporting requirements are included in this package and must be followed when those reports are prepared.
note: When questions arise regarding the program, submit them by e-mail to the LITC Program Office at: [email protected]. If you are an existing clinic, you may also submit questions to the analyst assigned to your geographic location (See
the LITC Program Office Organization Chart).

II

LITC PROGRAM OVERVIEW
IRC § 7526 authorizes the IRS to award matching grants of up to $100,000 per year to qualifying organizations

that represent low income taxpayers involved in controversies with the IRS and to organizations that provide education
and outreach on the rights and responsibilities of U.S. taxpayers to individuals who speak English as a second language
(ESL). IRC § 7526 requires clinics to provide services for free or for no more than a nominal fee.
Low income status is determined by reference to the Federal Poverty Guidelines, which are updated annually by the
Department of Health and Human Services (HHS). Applications are accepted for project periods of up to three years
duration. Funding is provided for budget periods of one year, subject to the availability of annually appropriated funds.
The budget period is known as the grant cycle, which begins on January 1 and ends on December 31. With respect
to applications for two or three-year project periods, the second and third years will be funded subject to satisfactory
performance, compliance with grant terms, and availability of appropriated funds. All grant funds awarded to an LITC
must be used for the LITC program specifically authorized in the grant.
The LITC Program is administered by the Taxpayer Advocate Service (TAS). The Director of the LITC Program
Office reports directly to the National Taxpayer Advocate and is responsible for providing oversight, guidance, and assistance to LITC grantees and prospective applicants.

III

DEFINITIONS
A “taxpayer” eligible for assistance from a clinic is an individual rather than an entity. There may be times,

however, that a clinic may be dealing with an entity’s tax issues in order to assist the individual. For example, if the
individual owns a sole proprietorship, and the sole proprietorship has an employment tax controversy, a clinic may
provide assistance with the employment tax controversy, as the individual is ultimately the taxpayer responsible for the
employment tax liability. Similarly, if an individual is the sole shareholder in an S corporation and the S corporation has
a tax controversy which impacts the individual’s income tax liability, the clinic may provide assistance.
The term “clinic” includes, but is not limited to:
 A clinical program at an accredited law, business or accounting school in which students represent low

income taxpayers in controversies with the IRS; and

4 An organization described in IRC § 501(c) and exempt from tax under IRC § 501(a) that either directly

represents taxpayers or refers taxpayers to qualified representatives.

6

LOW INCOME TAXPAYER CLINIC

Examples of qualifying “controversy” activities include:

4 Handling a taxpayer’s IRS account, collection, examination, or Appeals matter;

4 Representing a taxpayer on a federal tax matter in federal courts, including the United States Tax Court;

4 Providing assistance to a nonfiler in the preparation of prior year return(s), as long as the clinic has entered

into a representation agreement with the nonfiler;

4 Providing assistance to a victim of identify theft on a federal tax matter, or a state tax matter when the clinic is

representing or referring that taxpayer in a federal tax controversy;

4 Preparing an amended return, if such assistance is necessary to resolve a controversy for which an LITC is

representing a taxpayer; and

4 Representing or referring a low income taxpayer involved in a state or local tax controversy, when the clinic is

representing or referring that taxpayer in a federal tax controversy.
The “referral” activity for which grant funds may be expended is the referral of low income taxpayers to a pro bono
panel – one that provides representation free of charge. A pro bono panel consists of qualified representatives, nonprofit entities or other organizations that do not charge for representing low income individuals.
A “qualified representative” is any individual who is authorized to practice before the IRS (e.g., attorney, certified
public accountant, enrolled agent) or applicable court. Any controversy clinic that does not have a staff member who
is admitted to practice before the United States Tax Court must have a pro bono panel member who is admitted to practice before the United States Tax Court and to whom the clinic can refer litigation matters. See Tax Court Rule 200,
available at www.ustaxcourt.gov for information about gaining admission to practice before the Tax Court.
A “program to inform” is one in which the clinic educates ESL individuals about their rights and responsibilities as
U.S. taxpayers.
Examples of qualifying “ESL activities” include:

4 An outreach event such as fairs, forums, and meetings to inform the public about clinic services;

4 An educational workshop or program about federal taxpayer rights and responsibilities conducted by a clinic

and attended by ESL taxpayers;

4 Direct consultation with ESL taxpayers regarding their rights and responsibilities as U.S. taxpayers; and

Ancillary assistance to ESL taxpayers in the preparation of federal tax returns or other required tax forms (see Treas.
Reg. § 301.7701-15(f)(2)).

IV

LITC PROGRAM GRANT REQUIREMENTS

A. Eligibility Criteria

1. IN GENERAL
The organization must be a qualified clinic that represents or refers low income individual taxpayers (to a pro
bono panel) in controversies with the IRS or operates programs to inform ESL taxpayers about their rights
and responsibilities as U.S. taxpayers. Additionally, qualified clinics must offer services for free or for no more
than a nominal fee.
The organization may be a clinic providing qualifying services that it conducts within a broader spectrum of
activity. A clinic may provide representation in nontax matters as well as representation in tax matters as long
as grant funds are used only to support representation in tax matters. Such clinics must reasonably allocate
their expenses and matching funds for services shared with nonqualifying programs or other organizations
in determining allowable expenses for LITC funding and their compliance with the statutory matching funds
requirement. A clinic may not make a subgrant of LITC grant funds to another organization.

7

 S
 tart-Up Expenses.

Start-up operations qualify for grant funding. Thus, a clinic may be awarded an LITC

grant although it anticipates that it will not begin operating until after the close of the grant cycle for which
the grant is awarded. Such applicants still must satisfy the statutory matching funds requirement during the
year covered by the grant and must meet all reporting requirements to provide information on the status of the
start-up. In addition, LITC grants to these applicants will be conditioned on the conduct of qualifying activities
during the immediately succeeding grant cycle.
 N
 ominal Fee.

IRC § 7526 provides that a clinic must not charge more than a nominal fee for clinic services, in

addition to reimbursement of actual costs incurred (e.g., photocopying and court costs). If a clinic is charging a
fee, the clinic must charge that same fee to everyone, regardless of the services being sought. Remember: The
goal of the LITC Program is to enhance access to legal services for low income taxpayers. If the amount that a
clinic charges results in fewer taxpayers served, the goal of the Program is not being achieved and that amount is
not nominal.
note: A clinic may not charge a separate or additional fee (even if it is nominal) for the preparation of a tax return (except for
reimbursement of actual costs incurred, e.g., photocopying).

2. CONTROVERSY CLINIC REQUIREMENTS
 90/250 Income Requirement.

A low income taxpayer is an individual whose income does not exceed 250

percent of the Federal Poverty Guidelines published annually by HHS. At least 90 percent of taxpayers
represented or referred must have incomes that do not exceed 250 percent of the Federal Poverty Guidelines.
A clinic must use the LITC Program’s poverty guidelines to determine whether a client seeking representation is
a low income taxpayer for purposes of LITC Program funding. A clinic must base its determination of whether
a taxpayer satisfies the income requirement on current income information. The taxpayer must provide this
information on an intake form (or similar form) at the time the taxpayer seeks the clinic’s assistance. Changes in
financial status during representation do not disqualify clients from continuing to receive clinic representation.
A clinic may consider the taxpayer’s current year return in determining the taxpayer’s income, as defined below.
Whether the 90/250 income requirement is met is determined based on the taxpayers actually represented. For
this purpose, representation occurs when the arrangement is memorialized through a letter of engagement, a
pro bono representation agreement, or a Form 2848, Power of Attorney and Declaration of Representative. For
purposes of determining the total number of taxpayers represented in controversies with the IRS, include both
those who do and do not meet the income requirements. Preparation of a joint return counts as two taxpayers
assisted. If only one spouse on a joint return is represented or referred, the represented spouse counts as one
taxpayer assisted.
Satisfaction of the 90/250 income requirement is determined based on the income of family units, not on the
average income of the taxpayers represented. For example, suppose a clinic has the following clients: 97 unrelated individuals (i.e., 97 family units) and one family unit of three related taxpayers. For purposes of determining whether the 90/250 income requirement is satisfied, at least 90 percent of the 98 family units must have
incomes which do not exceed 250 percent of the Federal Poverty Guidelines.
A clinic must maintain records for the total number of taxpayers represented in controversies with the IRS, and the
number of taxpayers represented in controversies with the IRS who have incomes that do not exceed 250 percent
of the Federal Poverty Guidelines and whose cases meet the amount in controversy requirement (see below).

8

LOW INCOME TAXPAYER CLINIC

 Current Poverty Guidelines. The LITC Program Office updates the poverty guidelines for the LITC Pro-

gram annually after HHS updates the Federal Poverty Guidelines each year to account for inflation. Clinics
must adopt the new income ceilings for determining LITC low income representation eligibility within 30
days from the date of publication of the HHS Federal Poverty Guidelines in the Federal Register.
As of the time this package was printed, HHS had not updated the Federal Poverty Guidelines and the 2009
Guidelines remained in effect. Thus, based on the Federal Poverty Guidelines published at 74 F.R. 4199 on
January 23, 2009, the income ceilings for low income representation are as follows:

Income Ceiling (250% of Federal Poverty Guidelines)

Size of Family Unit

48 CONTIGUOUS STATES, PUERTO RICO, AND D.C.

ALASKA

HAWAII

1

$27,075

$33,825

$31,150

2

$36,425

$45,525

$41,900

3

$45,775

$57,225

$52,650

4

$55,125

$68,925

$63,400

5

$64,475

$80,625

$74,150

6

$73,825

$92,325

$84,900

7

$83,175

$104,025

$95,650

8

$92,525

$115,725

$106,400

For each additional
person, add

$9,350

$11,700

$10,750

Before determining whether a taxpayer is eligible for LITC assistance, please refer to http://aspe.hhas.gov/
poverty/index.shtml for any updates.

Definition of Income for Purposes of the 90/250 Income Requirement
“Income” is defined in accordance with the definition used by the U.S. Bureau of the Census. See http://www.
census.gov/population/www/cps/cpsdef.html for the complete list of items included in the definition of income.
Income includes total annual cash receipts before taxes with the exceptions provided below. For example,
income includes salaries before deductions, net receipts from self-employment (receipts after deductions
for business expenses), alimony, child support, federally funded and other public assistance, social security,
private pensions, scholarships, dividends, interest, net gambling winnings, and survivor benefits or annuity
payments.
Income does not include proceeds received from the sale of property (including stocks, bonds, a house, a
car), withdrawals from a bank account, tax refunds, gifts, loans, a lump sum inheritance, one-time insurance
payments, compensation for injury, or noncash benefits (e.g., employer-paid or union-paid portion(s) of
employee fringe benefits).

9

Definition of Family Unit
For purposes of this grant program, a family unit is defined as an unrelated individual or a family. An unrelated
individual is a person 15 years old or over who is not living with persons related by birth, marriage, or adoption.
A family is a group of two or more persons related by birth, marriage, or adoption who live together. However, if related individuals live together, but the person seeking assistance from the clinic is financially independent, then that
person may be treated as a family unit. If two unrelated individuals live together, they constitute two family units.

Amount in Controversy
The amount in controversy for any taxable year generally should be within the amount specified in IRC § 7463
(currently $50,000). The amount in controversy includes penalties, but does not include interest. If a clinic
takes on a case in which the amount in controversy exceeds the amount specified in IRC § 7463, the clinic
must maintain in its case file an explanation of why the case was accepted and provide the number of such
cases in its Interim and Year-End reports.

3. ESL CLINIC REQUIREMENTS
Outreach Activities. Clinics must identify their target audience and develop an outreach strategy to reach
that audience. An educational outreach program is a program designed to educate ESL taxpayers about their
federal taxpayer rights and responsibilities. Examples of educational outreach programs:


One-on-one consultations;



Holding a workshop on collection alternatives or employee/independent contractor status;



Making a presentation about federal taxpayer rights and responsibilities to an ESL class at a local community college;



Staffing a table at a community event and handing out clinic brochures and educational materials about various tax issues, and then answering questions and scheduling appointments for interested taxpayers; and



An outreach program at a local community center where the clinic holds weekly discussions during the
filing season to educate ESL taxpayers about choosing a tax return preparer, family and education credits,
refund anticipation loans, Individual Taxpayer Identification Numbers (ITINs), and other related issues.

Publicity. In addition to conducting outreach activities, ESL clinics are encouraged to reach out to their target
audience through publicity efforts. LITCs receiving funding for qualifying ESL activities must advertise and promote themselves as providing information and education to help ESL individuals understand the federal tax system. For example, an LITC could advertise a community meeting to acquaint ESL individuals with their rights
and responsibilities under the federal tax system. Additionally, clinics are encouraged to include substantive tax
information (e.g., when to file, what forms to file, who is eligible for the Earned Income Tax Credit (EITC), information about the audit and appeals process, collection alternatives, or employee versus independent contractor
status, through indirect outreach efforts.

Ancillary Tax Return Preparation. An ESL clinic can provide assistance with a tax return or a claim for
refund under subtitle A and not be considered an income tax return preparer if such assistance is an ancillary
part of the clinic’s program. The term “ancillary” means incidental. That is, the LITC’s program must focus on
outreach and education and not tax return preparation. If, for example, an ESL client requests help with a tax
return in the course of an LITC conducting outreach or education activities, the LITC may not provide such
assistance unless it arises from the LITC’s primary activity of outreach and education. Clinics that engage in
ancillary tax return preparation cannot charge a separate fee (even if it is a nominal fee) for this service.

note: Tax return preparation assistance that is directly related to a controversy is not considered “ancillary” and is permitted
under the definition of “controversy”. The clinic may not charge a fee for the preparation of such returns.

10

LOW INCOME TAXPAYER CLINIC

Tax Preparation Referral. Generally, if ESL taxpayers require tax preparation assistance, they should be
referred to a Volunteer Income Tax Assistance (VITA) program or a Tax Counseling for the Elderly (TCE) site
(including a co-located independently funded program), or an IRS Taxpayer Assistance Center, where available. Grant funds awarded to an LITC must be used for the LITC activities authorized in the grant agreement
and cannot be used to fund VITA or TCE activities.
Fees. IRC § 7526 provides that a clinic must not charge more than a nominal fee for clinic services, in addition to reimbursement of actual costs incurred (e.g., photocopying and court costs). If a clinic is charging a
fee, the clinic must charge that same fee to everyone, regardless of the services being sought. Note: A clinic
cannot charge a separate or additional fee (even if it is nominal) for the preparation of a tax return (except for
reimbursement of actual costs incurred, e.g., photocopying).
Pro Bono Referral Panel. Programs that inform ESL taxpayers about their federal taxpayer rights and responsibilities are required to maintain a pro bono referral panel to which they may refer federal tax controversies. An ESL clinic can also refer taxpayers to another LITC; however, controversy funding will not be awarded
to an organization that is solely making referrals to another LITC.

What is a pro bono panel?
Examples of pro bono panels to which taxpayers may be referred include:
 A panel of qualified representatives maintained by the clinic to whom the clinic refers matters and who

agree to provide pro bono representation to low income taxpayers;
 A panel maintained by a state bar association that makes referrals, for free or for a nominal fee, to

qualified representatives who have agreed to provide pro bono representation; and

 A panel maintained by a state or local society of accountants that makes referrals, for free or for a

nominal
fee,
to
qualified
representatives
who
have
agreed
to
provide
pro
bono
assistance
to
taxpayers.

4. MATCHING FUNDS REQUIREMENTS
All applicants must provide matching funds on a dollar-for-dollar basis for all LITC Program grant funds received.
 Qualified Matching Funds include (but are not limited to):

a. Cash contributions;
b.

Third party in-kind contributions (donated property or services);

c.

Salary, including fringe benefits, paid for the individuals performing services for the clinic;

d. The value of volunteer services furnished by professional and technical personnel, consultants and other
skilled and unskilled labor, if the services are an integral and necessary part of an approved project or program;
e
 . The value of services provided by a clinic employee beyond the hours for which the employee is being

paid, if the services are an integral and necessary part of an approved project or program;
f.

The cost of equipment used in the clinic;

g.

The fair market rental value of office space provided to the clinic;

h.

Reasonable office supplies and equipment costs; and

i. Program income from activities that are directly related to the clinic’s objectives (e.g., registration fees for

training and technical assistance programs for tax practitioners who serve the low income community,
registration fees for informational programs for ESL taxpayers, and nominal fees for the clinic’s services).

11

 Ineligible Matching Funds include (but are not limited to):
a.

Services provided by students in exchange for academic credit;

b.

Federal work-study funds;

c. Funds from other federal grants unless specifically authorized by statute
(See OMB Circular A-110, Subpart C, § .23);
d.

Legal Services Corporation funds;

e.

Purchase, construction, repair, or rehabilitation of any building or any portion thereof;

f. Expenses incurred which do not support or benefit the program; and
g. Indirect expenses, including general overhead of the institution sponsoring the clinic, except for
salaries and equipment as indicated above. General overhead includes operation and maintenance
expenses and depreciation.
note: OMB guidance restricts percentages of overhead that can be allocated as matching funds.
 Volunteer Services.

The rates for volunteer services shall be determined consistent with the principles stated

in OMB Circular A-110, “Uniform Administrative Requirements for Grants and Agreements with Institutions
of Higher Education, Hospitals, and Other Non-Profit Organizations”, Subpart C, § .23.
 Documentation of Matching Funds Sources.

LITCs must maintain adequate records to substantiate the

source of all matching funds. For example, if the clinic is counting services provided by employees or volunteers as
matching funds, the clinic must track the amount of time employees or volunteers spend working on LITC activities (e.g., a clinic can use sign-in sheets, timesheets, or some other similar method to track the time). The Program
Office has provided the Volunteer and/Pro Bono Time Reporting Form as an example of a tool that could be used
to track the services provided by volunteers. See Appendix C, Supplemental Issues Forms and Instructions.
While grant awards may be made based on good faith estimates of matching funds, including verifiable pledge
commitment(s) or likely sources of funding, clinics must provide adequate documentation regarding the committed sources of matching funds. For a clinic to obtain a grant payment in advance of actual disbursement
or receipt of the required nonfederal match, the clinic generally must have firm commitments for the required
matching funds. A firm commitment consists of a binding written agreement between the grantee and the
source of the matching funds that is conditioned solely upon the availability of federal assistance (and such
other conditions as approved in advance by the IRS).
note: See “Managing Funds” for additional examples of qualifying and ineligible matching funds.

B. Office of Management and Budget (OMB) Requirements
Grant award administrative requirements are set forth in OMB Circulars. The basic administrative requirements applicable to individual Grant Agreements are contained in:
 OMB Circular No. A-110, “Uniform Administrative Requirements for Grants and Agreements With Institu-

tions of Higher Education, Hospitals, and Other Non-Profit Organizations”;
 OMB Circular A-133, “Audits of States, Local Governments, and Non-Profit Organizations”;
 OMB Circular A-21, “Cost Principles for Educational Institutions”; and
 OMB, Circular A-122, “Cost Principles for Non-Profit Organizations.”


All applicable provisions of these circulars, as revised, and any existing and further supplements and revisions are incorporated into these program requirements and into all grant agreements entered into between the IRS and clinics. These
circulars are incorporated into Title 2 of the Code of Federal Regulations.

12

LOW INCOME TAXPAYER CLINIC

C. Audit Requirements
OMB Circular A‑133 describes the audit requirements applicable to grantees. If you expend less than $500,000 a year
in total federal awards, no OMB audit requirements are applicable. (See OMB Circular A-133, Subpart B, § .200(a)).
The IRS, however, has the right to audit expenditure of LITC funds regardless of the dollar amount of federal funding
received by the grantee.
If you expend $500,000 or more a year in federal awards, you must provide the IRS with a copy of the results of an
audit performed in compliance with OMB Circular A-133. You must arrange for an audit by an independent auditor in
accordance with the Government Auditing Standards developed by the Comptroller General of the United States. The
costs of audits performed in compliance with OMB Circular A-133 are allowable LITC grant expenses.
An audit under OMB Circular A-133 is organization‑wide. The auditor must determine whether:
 Your financial statements present fairly your financial position and the results of your operations in accordance

with generally accepted accounting principles;
 You have an internal control structure to provide reasonable assurance that you are managing federal awards

in compliance with applicable laws and regulations, and controls that ensure compliance with the laws and
regulations that could have a material impact on the financial statements; and
 You have complied with laws and regulations that may have a direct and material effect on your financial state-

ment amounts and on each major federal program.
Financial records, supporting documents, statistical records, and all other records pertinent to an award shall be
retained for a period of three years from the date of submission of the final report for the grant cycle, subject to certain
exceptions set forth in OMB Circular A-110.
The LITC Program Office continues to incorrectly receive requests for grant payment information as LITCs undergo
their independent audit examinations. To obtain grant payment confirmation, recipients should contact the Department of Health and Human Services / Division of Payment Management directly at www.dpm.psc.gov, or contact
Sheila Swedenburg at 301-443-7993 (not a toll-free call).

D. Civil Rights Reporting Requirements
This information is being collected to enforce Title VI of the Civil Rights Act of 1964, as amended, which prohibits
discrimination on the basis of race, color, or national origin in any program or activity receiving federal funds; Title IX of
the Education Amendments of 1972, as amended, which prohibits discrimination on the basis of sex in any education program or activity receiving federal funds; § 504 of the Rehabilitation Act of 1973, as amended, which prohibits discrimination on the basis of disability in any program or activity receiving federal funds; and the Age Discrimination Act of 1975, as
amended, which prohibits discrimination on the basis of age in any program or activity receiving federal funds.
This section describes the data collection and reporting requirements required of LITC grant applicants by the IRS
to meet its responsibilities under these laws. This information is required pursuant to the civil rights statutes and the
regulations of the Department of Justice and the Department of the Treasury.
This information is mandatory and required of every applicant annually. As a condition of eligibility under the LITC
Program, the applicant must provide the following information in its grant application package:


1. A list of active lawsuits or complaints naming the applicant which allege discrimination on the basis of race,

color, national origin, age, sex, or disability with respect to service or benefits being provided. The list should
include: the date the lawsuit or complaint was filed; a summary of the allegation; and the status of the lawsuit
or complaint, including whether the parties to a lawsuit have entered into a consent decree.

13

2.

A description of all pending applications for financial assistance and all financial assistance currently provided
by other federal agencies. For all applicants for IRS financial assistance, this information should be relevant to
the organizational entity actually submitting the application, not necessarily the larger agency or department
of which the entity is a part.



3. A summary of all civil rights compliance review activities conducted in the last three years.

The summary shall

include: the purpose or reason for the review; a summary of the findings and recommendations of the review;
and a report on the status or disposition of such findings and recommendations. For all applicants for IRS
financial assistance, this information should be relevant to the organizational entity actually submitting the
application, not necessarily the larger agency or department of which the entity is a part.

4. A signed and dated Standard Form 424, with box 21 checked (see Appendix A) agreeing to the statement of

assurance concerning civil rights compliance.

5. The External Civil Rights Team of the IRS may request additional data only to the extent that it is readily avail-

able or can be compiled with reasonable effort, and is found to be necessary to make a civil rights compliance
determination. Examples of data and information which, to the extent necessary and appropriate for determining
compliance with applicable civil rights statutes and implementing regulations may be as follows, but not limited to:


The manner in which services are or will be provided by the program in question, and related data necessary for
determining whether any persons are or will be denied such services on the basis of prohibited discrimination;



The population eligible to be served by race, color, national origin, age, sex, or disability;



Data regarding covered employment, including use or planned use of bilingual public contact employees
serving beneficiaries of the program where necessary to permit effective participation by beneficiaries
unable to speak or understand English;



The location of existing or proposed facilities connected with the program, and related information adequate for determining whether the location has or will have the effect of unnecessarily denying access to
any persons on the basis of prohibited discrimination;



The present or proposed membership, by race, color, national origin, sex, age, or disability, in any planning
or advisory body which is an integral part of the program; and



Data, such as demographic maps, the racial composition of affected neighborhoods or census data.

Each multi-year applicant shall update the civil rights reporting requirement information annually. Each application for
financial assistance shall be reviewed for its civil rights reporting requirements by an External Civil Rights Team staff
member. Upon completion, the reviewer shall forward a letter of compliance to the applicant indicating the civil rights
determination. Financial assistance shall not be awarded to the applicant until the civil rights reviewer has issued a
finding of compliance or conditional compliance. Department of Justice regulations state that all federal agency staff
determinations of Title VI compliance shall be made by, or be subject to review by the agency’s civil rights office.
Each Low Income Taxpayer Clinic is required to display the Civil Rights Poster, Publication 4025.

If you need additional information or have any questions, please contact the Director, Civil Rights Division (External
Civil Rights Team), at (202) 927-0180.

E. Lobbying Restrictions (18 U.S.C. § 1913; 31 U.S.C. § 1352; 31 CFR, Part 21)
PROHIBITION ON USING GRANT FUNDS FOR LOBBYING CONGRESS
Under 31 U.S.C. § 1352(a), recipients of Federal grants are prohibited from using appropriated funds “to pay a person
for influencing or attempting to influence” the executive or legislative branches of the government with respect to any
federal grant.  Persons requesting or awarded a single grant exceeding $100,000 must certify that they have not, and will
not, use the grant funds in a manner prohibited by 31 U.S.C. § 1352(a). See 31 C.F.R. § 21.110(a)-(b). In addition, 18
U.S.C. § 1913 prohibits the use of appropriated funds for lobbying and provides that violations of this restriction will
constitute a violation of 31 U.S.C. § 1352(a).

14

LOW INCOME TAXPAYER CLINIC

Section 1352 of 31 U.S.C. also requires that any lobbying activities (e.g., those conducted with non-federal funds) be
disclosed by each organization that receives or accepts a federal grant of more than $100,000 per year.  The requirements to certify and disclose are based on the award amount of a single grant rather than an aggregate of all federal
grants awarded to an organization during the year. 
Because the maximum amount the IRS is allowed to award to any LITC pursuant to IRC § 7526(c)(2) is $100,000 per
year, the requirements to certify and disclose lobbying activities with respect to such a grant are not applicable, unless
an LITC receives a federal grant of more than $100,000 from another federal program. The reporting period for disclosure of lobbying activities, if applicable, is the same as the grant cycle.

LOBBYING FOR PURPOSES OF 31 U.S.C. § 1352
Influencing or attempting to influence for purposes of 31 U.S.C. § 1352 means making, with the intent to influence,
any communication to or appearance before an officer or employee of any agency, a Member of Congress, an officer or
employee of Congress, or an employee of a Member of Congress in connection with the making or extending of a grant.
Lobbying that is prohibited by 18 U.S.C. § 1913 (and consequently prohibited by 31 U.S.C. § 1352) consists of paying
for any personal service, advertisement, telegram, telephone, letter, printed or written matter or other device, intended
or designed to influence a Member of Congress or other government official with respect to legislation.

LOBBYING FOR PURPOSES OF IRC § 501(C)
While engaging in lobbying activities without spending grant funds does not violate 31 U.S.C. § 1352, there may
be IRC § 501(c) implications. IRC § 501(c)(3) organizations may conduct an insubstantial amount of lobbying and
still maintain their tax-exempt status.  The term “insubstantial” is not defined and depends on all the facts and circumstances (expenditures, volunteer time, time spent by officers and board, etc.).  An IRC § 501(c)(3) organization may
also voluntarily make a lobbying election under IRC § 501(h), where the amount of lobbying is limited to a percentage
expenditure test detailed in IRC § 4911 and the corresponding Treasury regulations.  
IRC § 501(c) does not define the term “lobbying.” For purposes of the lobbying election under IRC § 501(h), the
concept of “influencing legislation” is defined by cross-reference to IRC § 4911(d). IRC § 4911(d) defines influencing
legislation to mean the following:

a.

any attempt to influence any legislation through an attempt to affect the opinions of the general public or any
segment thereof, and

b.

any attempt to influence any legislation through communication with any member or employee of a legislative
body, or with any government official or employee who may participate in the formulation of the legislation.

LITC ACTIVITIES WITH POSSIBLE LOBBYING IMPLICATIONS
For example, an LITC may send an e-mail to the independently sponsored LITC listserve to gather support (or opposition) for legislation. Although such an e-mail is an attempt to influence legislation, so long as appropriated grant funds
are not used, the LITC has not violated Title 31 or Title 18. If the LITC has a requirement under Title 31 to report lobbying activities, the e-mail activity would need to be disclosed, including any research or background work performed
in connection with the e-mail to the listserve.
For purposes of IRC § 501(c), sending a single e-mail to the listserve would likely constitute an “insubstantial” amount
of lobbying. Because the use of a listserve is free, the LITC should not have any substantial expenditures in connection with the sending of the e-mail. Keep in mind that if an LITC anticipates devoting a large amount of time to the
endeavor (e.g., researching the issue, drafting proposed legislation, responding to comments on the listserve about the
proposal), the activity could rise to the level of being more than insubstantial, in which case the LITC may choose to
make a lobbying election under IRC § 501(h).

15

For more information about making a lobbying election, refer to:
 IRC § 501(h) and IRC § 4911
 Treas. Reg. §§ 1.501(h)-1 thru 1.501(h)-3
 Treas. Reg. §§ 56.4911-1 thru 56.4911-10
 Publication 557, Tax-Exempt Status for Your Organization.

LITCs receiving Legal Services Corporation (LSC) funds, should not confuse the above rules on lobbying with LSC
restrictions. There may be some lobbying activities that are acceptable under LITC guidance that are prohibited under
LSC requirements, and vice versa.

F. Trafficking Victims Protection Act of 2000, as amended (22 U.S.C. § 7104)
The Trafficking Victims Protection Act of 2000, as amended, requires any agency that awards grants to include a condition
authorizing the agency to terminate the grant if the grantee engages in certain activities related to trafficking in persons. As
part of the implementation of the Act, the Office of Federal Financial Management has established terms that must be put
in every grant agreement. See 2 C.F.R. § 175.15 (2007). Thus, if you receive a matching grant under this program:

1. You as the recipient, your employees, subrecipients under this award, and subrecipients’ employees may not:


Engage in severe forms of trafficking in persons during the period of time that the award is in effect;



Procure a commercial sex act during the period of time that the award is in effect; or



Use forced labor in the performance of the award or subawards under the award.

2. The IRS, as the Federal awarding agency may unilaterally terminate your award, without penalty, if you or a
subrecipient that is a private entity:


Is determined to have violated a prohibition in paragraphs (1)(i) – (iii) above of this award term; or



Has an employee who is determined by the IRS official authorized to terminate the award to have violated
a prohibition in paragraphs(1)(i) – (iii) of this award term through conduct that is either:
 Associated with performance under this award; or
 Imputed to you or the subrecipient using the standards and due process for imputing the conduct of

an individual to an organization that are provided in 2 CFR part 180, ‘‘OMB Guidelines to Agencies
on Governmentwide Debarment and Suspension (Non-procurement),’’ as implemented by the
Department of the Treasury at 31 CFR Part 19.

G. Other Applicable Laws and Regulations
Programs involving use of federal funds are governed by a wide variety of federal laws and regulations. These include:
 Restrictions on political activities at 18 U.S.C. §§ 595, 598, 600-603;
 The preservation requirements in the National Historic Preservation Act (16 U.S.C. § 470 et seq.) and the

Archeological and Historic Preservation Act of l966 (16 U.S.C. § 469a-1 et seq.);
 Environmental requirements of the Clean Air Act (42 U.S.C. § 7401 et seq.); and
 The non-pollution requirement of the Federal Water Pollution Control Provisions (33 U.S.C. § 1251 et seq.).

Assurances of compliance are required for LITC funding, according to the “common rule” on non-procurement, debarment and suspension adopted by Department of Treasury at 31 CFR, Part 19, Subpart C. This means you must submit a
statement that your organization and Clinic Director are not presently debarred or suspended from covered transactions
by any federal agency. In addition, you must indicate that within the three-year period before applying for a grant, your
organization and Clinic Director have not been convicted of or had a civil judgment rendered against them for fraud, theft
or certain other offenses, and have not had one or more public transactions terminated for cause or default. You must also
indicate that your organization and Clinic Director are not presently criminally or civilly charged with certain offenses.

16

LOW INCOME TAXPAYER CLINIC

Additional assurances are required according to the Government-wide requirements for a drug-free workplace (41
U.S.C. §§ 702-707), adopted by the Department of the Treasury at 31 CFR, Part 20, Subpart B and C, and assurance of
civil rights compliance, as specified above.
A signature is no longer required on individual Certification forms. After signing the Standard Form 424, check the box
on line 21 “I agree” to indicate your acceptance of the assurances provisions. The assurance provisions that accompany
Standard Form 424 appear in Appendix A.

H. LITC Grant Agreement
LITC organizations execute grant agreements with the IRS. The IRS, subject to the availability of appropriated funds, is
authorized to award grants to provide matching funds for the development, expansion, or continuation of qualified LITCs.
The LITC Grant Agreement lists the maximum amount of grant award, the type of services to be performed by the clinic,
the period covered by the grant, and incorporates by reference the requirements specified in the application package.
An LITC Program grant may be awarded for up to a three-year grant cycle. Grants for an approved program plan of
two or three years will be funded for each subsequent year subject to the availability of annually appropriated funds,
satisfactory performance, and compliance with grant terms. Although the LITC Program generally adheres to Circular
A-110, the provision in Subpart C, § .62(b) regarding hearings and appeals does not apply to LITC grant recipients;
Circular A-110 only requires an agency to provide a grant recipient with an opportunity for a hearing, appeal, or other
administrative proceeding if the statute or regulation authorizing the particular grant program provides for one. IRC §
7526 does not require the IRS to provide grant recipients an opportunity for hearing or appeal. Therefore, the necessity
for renegotiation, suspensions, or terminations of grant agreements will be determined solely by the IRS and will not be
subject to appeal. The grant agreement shall be terminated and enforced in accordance with OMB Circular A-110.

I. Operational Requirements
Each LITC will be held to certain operating and ethical standards during the duration of the grant cycle.

1. STANDARDS OF OPERATION.
The LITC Program Office has developed baseline standards of operation for LITC grant recipients. The
standards ensure that all LITCs provide consistent and quality service to low income and ESL taxpayers and
ensure that all LITCs are accountable for meeting the LITC Program requirements.


Qualified Tax Expert (QTE)—Availability of staff member with tax law expertise.
In general, the QTE must be an Attorney, CPA, or Enrolled Agent currently authorized to practice before
the IRS. However, consideration may be given to an applicant who can demonstrate tax expertise because
of a related academic degree, documented experience or Continuing Professional Education credits.
The QTE will assume oversight of technical substantive tax matters.
Funding will not be released until the QTE has been designated and is on staff.



Qualified Business Administrator (QBA)—Availability of staff member with business administration expertise.
If a department, as opposed to a single individual, fulfills this requirement, please provide detail about the
staff member who oversees the department.
The QBA must demonstrate education or experience with business or program administration, such as,
but not limited to, internal controls, management of federal, state or local grant funding, budget administration and procurement, or the equivalent.
The QBA will have oversight of the clinic’s business operations.

17



Clinic Director – Availability of staff member with overall management responsibility for the clinic.
The Clinic Director may be the QTE, QBA, or other clinic staff member. The Clinic Director is responsible for managing the clinic, preparing or reviewing the required clinic reports, and signing the reports as
the clinic’s authorized representative. The Clinic Director serves as the primary contact person for both
the LITC Program Office and the Local Taxpayer Advocate’s office.



Publicity/Outreach – Effective publicity/outreach efforts to targeted audience.
LITCs must identify their target audience and develop and describe the outreach strategy to reach that
audience. LITCs should also implement a process that tracks how participants hear about the program
and the services offered. For example, an intake form could be used to request this information. For ESL
outreach/education seminars, the clinic could request that attendees indicate on a sign-in sheet how they
learned about the seminar. The sign-in sheet also allows the clinic to keep track of the number of attendees served, without requiring individual names or signatures.
Grantees are responsible for effectively publicizing the LITC Program to low income taxpayers and ESL
taxpayers. Publicity plans should be completed well in advance of the period during which representation
and other assistance will be offered.
Although LITCs may prepare tax returns and claims for refund in two limited contexts (if related to a
controversy or an ancillary part of an ESL program) (see pages 2 and 6 of this Publication), publicity
materials and announcements to advertise the services provided by an LITC may not mention tax return
preparation or refund claim assistance.
Brochures, flyers, or other clinic information distributed in IRS offices must contain language to indicate
the following two key principles: (1) Although the clinic receives funding from the IRS, the clinic and its
employees and volunteers are not affiliated with the IRS, and (2) A taxpayer’s decision to use the LITC
will not affect the taxpayer’s rights before the IRS.
Such disclaimers need not be worded exactly as above, but must convey these principles.
The LITC Program recognizes the importance of using pamphlets, brochures, and other advertisements
to reach its target audience. Clinics should include substantive tax information in outreach efforts.The
information presented in these outreach materials should be broad-based and cover a variety of relevant
tax topics. Whenever possible, clinics are encouraged to use face-to-face contact (whether in one-onone consultations or in a group workshop), as it is an excellent method for educating taxpayers.



Mentoring Programs—Availability of mentoring and other technical assistance for clinic staff and volunteers.
Experienced LITCs may be asked to informally assist less experienced clinics with operational inquiries and
technical matters or issues. All clinics are encouraged to identify best practices and submit them to the LITC
Program Office for sharing with other clinics to improve the overall quality of the LITC Program.



Networking—Development and maintenance of relationships with other community-based organizations.
In the program plan, the LITC must identify networks within the community or organizations with which
it can work to reach its target audience.



Tax Library—Accessibility to and adequacy of tax library and research arrangements.
Each clinic must have access to a current hard copy version of the Internal Revenue Code and Treasury
Regulations.



Continuing Professional Education (CPE)—Each clinic must provide quality training to the clinic
staff, volunteers and other program participants to increase knowledge and skills necessary to effectively
deliver the services for which the clinic is funded. The QTE will be required to ensure and document that

18

LOW INCOME TAXPAYER CLINIC

the LITC staff, volunteers, and other program participants receive appropriate training to enhance skills.
The QTE, QBA and Clinic Director are encouraged to attend CPE programs run by the IRS and professional organizations.
All clinics must attend the annual LITC conference. The cost of attending the LITC Conference (e.g.,
transportation, hotel) should be included in an applicant’s request for grant funding as a separate line
item. If a clinic wishes to send more than two staff members to the conference, the clinic must submit
a written request to the Director of the LITC Program Office no later than two weeks in advance of the
conference. Please note, however, that clinics cannot use LITC grant funds or matching funds for more
than two attendees, except with respect to new clinics described below.
For all clinics: The Clinic Director must attend the annual LITC conference. If the Clinic Director is
not the QTE, we encourage both to attend the annual conference. If the Clinic Director cannot attend the
conference, a request for an exception must be submitted in writing to the Director of the LITC Program
Office no later than two weeks prior to the conference.
For new clinics: The individual responsible for grant administration and reporting must attend a mandatory conference call that will be held prior to the annual LITC Conference. That individual is not required
to attend the conference (unless he or she is also the clinic director), but may choose to attend.
For all clinics: Any requests for an exception to the clinic attendance rules for the annual LITC conference must be submitted in writing to the Director of the LITC Program Office no later than two weeks prior
to the conference. The waiver request should include the critical reason for the exception request, and the
name, title, and duties of the staff member requesting the exception. This waiver request includes clinics not
attending the conference at all or a request to leave the conference early.
note: The Program Office will provide a Certificate of Attendance for possible CLE or CPE credit. Applying to individual
state organizations (e.g., state bar, state CPA society, state association of enrolled agents) will be the responsibility of each individual seeking to obtain CLE or CPE credit for attending the annual LITC conference.


Qualified Volunteers—Qualifications, training, and background of volunteers used in the clinics.
Each LITC will develop a written application process or volunteer position description to determine
qualifications of volunteers – that is, training, educational background and other qualifications relevant to
the services offered by the clinic.



Referral Services—An LITC may refer taxpayers only to individuals authorized to practice before the
IRS. If controversy clinics maintain a referral panel for representing taxpayers in controversies, they must
establish adequate referral systems controls. Programs that inform ESL taxpayers about their taxpayer
rights and responsibilities must maintain a pro bono panel and must establish adequate referral system
controls. Clinics may have their own referral panel, a relationship with an existing referral panel, or both.
To expand clinic coverage, taxpayers with tax controversies may be referred to a panel of qualified representatives who have agreed to provide free representation or other assistance to taxpayers. Clinics are expected to have adequate procedures and a monitoring system in place to ensure such referrals are handled
expeditiously and that the actual representation by individuals is, in fact, pro bono. Pro bono representatives may not charge any fees for services (other than reimbursement of expenses such as photocopying
and court filing fees).
Controversy funding will not be awarded to an organization that is solely making referrals to
another LITC.
An LITC may only refer cases to other pro bono organizations, including a panel maintained by a state bar
association or a state or local society of accountants. Even if a taxpayer has income that exceeds 250 percent
of the Federal Poverty Guidelines, an LITC cannot refer the taxpayer to a representative who charges a fee;

19

an LITC should refer such a taxpayer to a state bar association, a state or local society of accountants, or enrolled agents, or other tax professional association that provides pro bono or nominal fee referrals. If that pro
bono organization ends up referring the taxpayer to a representative who does charge more than a nominal
fee, the LITC has still made an appropriate referral.
Generally, no one associated with the clinic should provide representation in a declined case. Additionally, no one employed by the clinic, or who serves as a volunteer, should continue providing representation in an accepted case or represent a clinic client in a subsequent, separate matter on a fee-for-service
basis. For example, an LITC holds an ESL outreach program where an accountant who is the QTE for the
clinic serves as a speaker. An ESL taxpayer who attended the outreach session later seeks to engage the accountant on a fee-for-service basis. Although the ESL taxpayer did not approach the LITC for representation, the accountant must decline representation of the ESL taxpayer unless the accountant is willing to
represent the ESL taxpayer on a pro bono basis.


Confidentiality—Assurance that taxpayer information will be kept confidential.
Tax professionals have ethical requirements to maintain client confidentiality. See, for example, American
Bar Association Model Rule of Professional Responsibility 1.6. Taxpayer information is confidential and
should be shared only on a limited basis. Grantees are responsible for ensuring that taxpayer information
is not compromised. Only those who have a need to know in order to effect resolution of the controversy
should be allowed access to taxpayer information.
Taxpayer information must be removed from materials before being used for teaching. This includes deletion of names, addresses, taxpayer identification numbers and any other information that could reasonably lead to identification of the taxpayer.
If a newspaper or other media reporter approaches clinic personnel to write an article about a taxpayer
served by the clinic, clinic personnel cannot provide details about any particular taxpayer’s case; a newspaper or other media reporter does not have a need to know of taxpayer information.
If a client approaches clinic personnel and asks the clinic to participate in a news article, the clinic must
obtain a written waiver for the disclosure of the client’s taxpayer information and clinic personnel must
be confident that the client fully understands the possible ramifications that could occur from disclosing
taxpayer information.
In terms of a client discussing with the media the particulars of his or her case, there is nothing in the LITC
Program Guidelines that would prohibit such an interview. However, this is an area where you should be
very cautious. You may want the interview to go forward as a way to advertise the services offered by your
clinic, but you cannot let this desire outweigh the best interests of your client.
By suggesting a potential interview to a client, the client may misunderstand and think you are encouraging
him or her to participate in the interview or that he or she is under an obligation to participate as a way of
thanking you for the services provided by your clinic. You should communicate to the client that he or she is
under no obligation to be interviewed. Make sure the client fully understands the possible ramifications that
could occur from disclosing personal information to a reporter. You do not know what potential issues other
than tax issues could be lurking (e.g., custody or support battles, other creditors, immigration) that could be
brought to light as a result of the media coverage.
In summary, any time you receive a request from the media for an article about one of your clients, you
need to act, first and foremost, in the best interests of your client. If the client chooses to participate in the
interview, suggest to the client that he or she make it a condition of the interview that the story be done
without photos and names.
While generally a grantee, its employees, and volunteers, are not treated as tax return preparers for purposes of preparer penalties, the Treasury Regulations under

20

LOW INCOME TAXPAYER CLINIC

IRC § 7216 define “tax return preparer” more broadly and generally prohibit a grantee, its employees, and
volunteers from disclosing or using a taxpayer’s return information except when the tax return preparer has
obtained prior written consent from the taxpayer in a manner that complies with the procedures set forth in the
regulations and other guidance issued by the IRS. The regulations authorize disclosure or use without consent
only in very limited situations. These situations include disclosures made pursuant to an order of a court or a
federal or state agency, and uses for purposes of preparation or audit of State or local tax returns. For unauthorized disclosure or use, IRC § 7216 imposes a sanction of up to one year in prison or a $1,000 fine, or both. In
addition, IRC § 6713 imposes a civil penalty of $250 for each disclosure or use, up to $10,000 per calendar year.
Clinics must keep taxpayer information in a secure location. Before clinic employees or volunteers leave
the office each day, they must make sure that taxpayer information is stored in a locked area. If it is necessary to take taxpayer information out of the office, it should be safeguarded at all times.


Recommended Back-up File System—Storing and securing electronic information.
A clinic should have a back-up file system in place for information stored on its computers and maintain the
back-up file off-site. This is good business practice and enables resumption of business in case of disaster or
other work stoppage. LITC funds may be used to purchase and develop a back-up file system.



Workgroup Service—Participation in an LITC workgroup.
Each clinic is required to provide a representative to serve on at least one LITC workgroup. These workgroups focus on substantive, administrative, and procedural tax issues that impact low income or ESL taxpayers. Examples of workgroups are the Earned Income Tax Credit (EITC), Individual Taxpayer Identification
Numbers (ITINs), Simplification of Notices Sent to Taxpayers, Financial Literacy, Multilingual Tax Initiatives, and numerous federal tax compliance issues (e.g., Federal Payment Levy Program, Offer In Compromise (OIC), Collection Due Process (CDP), and Refund Litigation). The LITC Program Office provides
guidelines to all clinics regarding the role of workgroups and the expectations for workgroup service.



Tax Compliance—Compliance with federal tax responsibilities throughout the grant cycle.
Clinics must be in full compliance with their federal tax responsibilities when applying for an LITC grant
and also throughout the grant cycle. To facilitate the resolution of any potential tax compliance issues, we
strongly encourage each clinic that is part of a larger organization (e.g., a university) to submit with its application package a completed Tax Information Authorization Form so that the LITC Program Office may
contact your office directly without violating IRC § 6103. For those clinics that are part of a larger organization, the absence of a completed form may require additional time to resolve any potential tax compliance
issues and could result in a delay in the receipt of grant funds.



Internal Controls—Assurance of compliance, safeguarding of assets, costs allowable, authorized and
allocable.
LITCs must create written procedures explaining the process for approving expenditures from grant
funds. The procedures should address which individuals have approval authority, when written approval
is required, and what documentation must be submitted in order for an expense to be approved by the
approving official. The approval process may differ based on size and type of expense.
LITCs must have written procedures to track the clinic’s fixed assets and inventory.



Recordkeeping—Maintaining adequate records to substantiate a claim for an attorneys’ fee award.
In certain situations, attorneys’ fees (including fees for pro bono services) may be awarded in a judgment
or settlement of an administrative or judicial proceeding concerning the determination, collection, or
refund of tax, interest, or penalty. See

21

IRC § 7430. Thus, a clinic doing controversy work should keep detailed contemporaneous records so that if
the situation arises, the clinic has adequate records to support an award for attorneys’ fees. Records should
include all time spent by employees, volunteers, and students of the clinic. The records should describe what
work was performed by each individual, the position of the individual (e.g., paralegal, attorney, volunteer,
student, etc.), and the amount of time spent on each task. The services provided by the clinic should be described in sufficient detail to enable the IRS and the court to assess the reasonableness of the amount of time
expended in relation to the service performed and to identify duplicated efforts by multiple clinic personnel.
The services can be identified using such classifications as: initial client interview; research (issue described);
gathering pertinent facts (describe information sought); preparation of court document; preparation of letter
(identify recipient and subject matter); analysis of records (identify records); consultation with third party
(describe relevance to case); and telephone conversations (identify the parties and the subject matter).

2. MANAGING FUNDS
The limitations below on allowable and unallowable expenses apply equally to matching funds as well as grant
funds. If, however, a clinic has funds available in excess of the required matching funds, these limitations do
not apply to the excess funds.

Allowable Expenses
Allowable expenses, which must be in accordance with the grant award including OMB Circulars A-122, “Cost
Principles for Non-Profit Organizations” and A-21, “Cost Principles for Educational Institutions”, as applicable, include (but are not limited to):


Salaries, wages, and personnel benefits;



Reasonable office supplies and equipment costs;



Rent, utilities, and custodial services;



Miscellaneous services, such as printing, postage, insurance, etc.;



Indirect costs as determined in accordance with principles set forth in OMB Circulars A-21 and A-122;



Audit services;



Publicity and training costs directly and solely associated with the program;



Installation of telephone lines necessary to provide representation to low income taxpayers or information
to ESL taxpayers;

note: To assist taxpayers in having the least cost in contacting a clinic for assistance, it is highly recommended that the clinic
have a toll-free number.


Travel performed by program administrator, coordinator, students or volunteers to conduct clinic business. Other travel in support of clinic activities such as meetings with the local Taxpayer Advocate and
Low Income Taxpayer Clinic Program sponsored LITC meetings;



Costs incurred in attending the mandatory annual LITC grant conference;

note: If you are a returning clinic, for purposes of attending the annual LITC conference, you have discretion as to whether to
use the funds for the upcoming grant cycle (i.e., funds for 2011, or funds for the current grant cycle (i.e., funds for 2010).


Costs incurred for interpreter services for hearing-impaired or non-English speaking taxpayers;



Cost of acquiring legal research and reference materials, including current copies of the Internal Revenue
Code and Treasury Regulations;



Providing refreshments (except alcohol) for community outreach events or one-on-one taxpayer consultations as long as the costs are reasonable. When determining whether the cost is reasonable, the expense
must be consistent with market prices.

22

LOW INCOME TAXPAYER CLINIC

note: A clinic may use grant funds for providing refreshments to volunteers so long as the costs are reasonable. However, a
clinic generally may not use grant funds to buy refreshments for its employees, unless their workload requires those employees to
work outside the normal hours of clinic operation.


Costs of acquiring pens, mugs and other small items of memorabilia for pro bono representatives working
with the clinic if the cost is reasonable. When determining whether the cost is reasonable, the expense
must be consistent with market prices.

Unallowable Expenses
Examples of expenses for which LITC grant funds may NOT be used include (but are not limited to):


Purchase, construction, repair, or rehabilitation of any building or any portion thereof;



Costs or expenses incurred which do not support or benefit the program, or which are unnecessary in
carrying out the program;



Certain advertising and public relations costs, as described in OMB Circular A-21, § J.1.f and OMB Circular A-122, Attachment B, § 1;



Purchase of alcohol. See OMB Circular A-21, § J.3 and OMB Circular A-122, Attachment B, Paragraph 3;



Use of grant funds to pay for lobbyist registration fees. See OMB Circular A-21, § J.28 and OMB Circular
A-122, Attachment B, Paragraph 25(a)(2);



Use of grant funds to obtain and maintain professional credentials for employees and volunteers, including application fees to become an attorney, CPA, or enrolled agent; bar dues; CPA dues; and the renewal
fee for enrolled agents. See OMB Circular A-21, § J.22 and OMB Circular A-122, Attachment B, § 19.

note: While maintaining professional credentials is generally a personal expense and therefore unallowable, you may
nonetheless use grant funds to pay for continuing education courses if such courses will increase the vocational effectiveness of
employees. See OMB Circular A-21, § J.51 and OMB Circular A-122, Attachment B, § 49;


Entertainment costs, as described in OMB Circular A-21, § J.17 and OMB Circular A-122, Attachment B,
§ 14; and



Costs of goods or services for personal use (as opposed to business use) of the clinic’s employees, as
described in OMB Circular A-21, § J.22 and OMB Circular A-122, Attachment B, § 19.

Payments To LITC Program Grantees
Grantees must have a signed grant agreement on file with the LITC Program Office and must provide written
assurances of specific matching funds prior to the payment of any funds. If expenses are incurred prior to approval, and the grant is later denied, all costs incurred will be the responsibility of the applicant.
Electronic Funds Transfer (EFT) payments shall be timed in accordance with the actual, immediate cash requirements of the recipient organization in carrying out the purpose of the approved program or project. The timing
and amount of EFT payments shall be as close as is administratively feasible to the actual disbursements by the recipient organization for direct program or project costs and the proportionate share of any allowable indirect costs.
LITC Program grant payments will be disbursed through EFT. Information regarding the EFT procedure
is available on the Division of Payment Management segment of the HHS website at www.dpm.psc.gov.
Questions regarding disbursements should be directed to the LITC Program Office at (202) 622-4711 or
[email protected].

23

When submitting the Interim financial report, the clinic must indicate whether it will be drawing down
the remainder of its grant award during the second half of the year. The clinic must also state whether it
expects to be deobligating funds and if so, how much. Because grant funds cannot generally be obligated
by the government after the end of the federal government’s fiscal year (September 30), and because of
the time involved to process a deobligation of funds and any potential obligation to another clinic, it is
important that a clinic notify the LITC Program Office immediately if that clinic will not be using its entire
award. The LITC Program Office will then contact the clinic shortly thereafter to arrange for a formal
release of LITC grant funds so that any obligation to another clinic can be accomplished before September
30. Unexpended grant amounts and advance payments must be returned to the Internal Revenue Service.

Advances of federal grant funds must be maintained in insured accounts. In addition, grantees shall maintain
advances of grant funds in interest bearing accounts, unless:


The grantee receives less than $120,000 in federal awards per year;



The best reasonably available interest-bearing account would not be expected to earn interest in excess of
$250 per year on federal cash balances; or



The depository would require an average or minimum balance so high that an interest bearing account
would not be feasible, given the grantee’s expected federal and nonfederal cash resources.

The clinic shall promptly, but at least annually, remit to the IRS interest earned on advances of federal grant
funds. However, interest up to $250 earned on all advances of federal grant funds per calendar year may be
kept by the clinic.
Clinics wishing to make minor adjustments to their program plan, such as shifting expenses between spending categories within the grant (e.g., shifting funds from travel to outreach), are not required to notify the Program Office
or seek written approval. See OMB Circular A-110, Subpart C, § .25. However, clinics making major changes to
their program plan must seek prior, written Program Office approval. The movement of funds between controversy and ESL activities is a major change to the program plan and must be approved in writing by the Program Office.
If a clinic is in doubt as to whether a reallocation is a major change, please seek guidance from the Program Office.
The LITC Program Office will monitor clinics’ use of funds throughout the year. If a clinic determines that it
will not use all of the funds awarded during the grant cycle, the LITC Program Office should be notified immediately in writing, by sending an e-mail to the clinic’s assigned analyst, and then following up with a letter.
This will give the LITC Program Office time to reobligate those funds to other clinics prior to September 30
(the end of the federal government’s fiscal year). The letter should include the amount being released, and the
reason that the amount awarded is being released.
The LITC Program Director must approve any changes to the above procedures in writing.

3. GRANTEE RESPONSIBILITIES
Program Management
Grantees are responsible for providing administrative support for the clinic by acting as managers or program
leaders for students, volunteers, and LITC employees. Grantees must:


State the amount of time managers or program leaders will devote to the LITC Program as well as the
amount of time that will be devoted to the management of students, volunteers, and LITC employees;

24

LOW INCOME TAXPAYER CLINIC



Provide training for students, volunteers, and LITC employees;



Obtain a special order from the IRS Office of Professional Responsibility for students who will be representing taxpayers before the IRS. If the clinic needs information about how to request a special order,
please contact Rita C. Barnett with the Office of Professional Responsibility at (202) 622-3530. Only
students who are enrolled in graduate business or accounting classes or law school programs qualify for
authorization by special order. The Office of Professional Responsibility authorization is limited to IRS
practice. Permission must be obtained from the courts for student representation. LITCs that receive
student authorization from the Office of Professional Responsibility must have their students revoke
any existing Forms 2848 on file with the IRS before leaving the program. If clinic students encounter
difficulty with getting Forms 2848 processed or with getting IRS personnel to recognize students as
authorized representatives, please contact the LITC Program Office at (202) 622-4711;



Monitor compliance of students, volunteers, and LITC employees with regard to program requirements
and guidelines outlined in grant agreement;



Maintain records of reimbursed expenses, if any, for students, volunteers, and LITC employees; and



Submit timely reports, prepared in accordance with the guidelines established in this Publication.

Changes In LITC Program Award-Supported Activities
Organizations should immediately notify the LITC Program Office of developments that have a significant
impact on the award-supported activities. Grantees must notify the LITC Program Office in the case of problems, delays, or adverse conditions that materially impair the ability to
meet the objectives of the award. This notification shall include a statement of the action taken or contemplated, and any assistance needed to resolve the situation. Failure to notify the LITC Program Office may result in
freezing of funds or termination of the grant.

LITC Contact Information
Clinics are required to confirm their contact information with the LITC Program Office twice a year. This
information includes the Clinic Director and contact person (and their phone numbers and e-mail addresses),
the clinic address (both the physical address and the mailing address), phone number, fax number, days and
hours of operation, and the beginning and ending dates clinic services will be provided. These requests ensure
that the Program Office has the most up-to-date information on each clinic.
If the location or phone number changes during the year, clinics should immediately notify the LITC Program
Office and submit a revised Form 13424, IRS Low Income Taxpayer Clinic (LITC) Application Information
Sheet, preferably by e-mail ([email protected]) or e-fax (877-477-3520). If the Program Office is
unable to locate the clinic or get in touch with the clinic, it may be necessary to freeze the clinic’s funding or
terminate the grant.

LITC Program Materials
Grantees are responsible for creating, printing, and distributing the educational program materials used in
conjunction with informing individuals of their taxpayer rights and responsibilities.

Withdrawal From LITC Program Or Termination Of Grant
A clinic must notify the LITC Program in writing before it withdraws from the Program or ceases to exist. All
unused funds must be returned to the IRS within two weeks of the date of withdrawal or the date of termination.
note: The federal government is generally obligated to charge interest on any amount that is not repaid in a timely fashion. See
31 C.F.R. § 901.9. Thus, for any funds the LITC Program Office requests to be returned to the IRS, failure to repay those funds
on time may result in the clinic having to pay interest on those funds.

25

If clinic activity is terminated prior to the expiration of the period of the grant agreement or if a clinic withdraws from the LITC Program, a final program and financial report must be submitted within 90 days of
final clinic activity or withdrawal from the program. Similarly, if the LITC Program Office terminates a grant
because of a clinic’s failure to comply with the LITC Program requirements, the clinic must submit a final
program and financial report within 90 days of the termination.
For employees and volunteers of the clinic who are lawyers, those individuals need to adhere to their responsibilities as lawyers, not just the responsibilities within the parameters of the LITC Program. The American Bar Association (ABA) has model rules of professional conduct that are applicable when a lawyer is terminating representation.
In this regard, ABA Model Rule 1.16 provides that upon terminating representation of a client, a lawyer must take
reasonable steps to protect a client’s interests, which includes giving notice to the client, allowing the client time to
find other representation, and returning papers/property to the client. Whichever state bar a lawyer is admitted
to will likely have a similar rule of professional responsibility that provides guidance for terminating representation.
In addition, if the clinic has an agreement with the U.S. Tax Court, the clinic must notify the Tax Court that the
clinic will not be continuing in the LITC Program so that the Tax Court does not refer taxpayers to that clinic.

Client Satisfaction
Clinics should solicit client comments regarding services provided and use such observations to improve clinic
services. Clinics should create a method of soliciting these assessments that is appropriate, depending on the
services provided to the client, but should be advised that this is optional.

J. Reporting Requirements
The LITC Program requires the timely submission of two reports during a grant cycle – an interim report and a YearEnd report. The LITC Program has adopted the following mission statement:
Low Income Taxpayer Clinics ensure the fairness and integrity of the tax system by educating low income taxpayers
about their rights and responsibilities, by providing pro bono representation to taxpayers in tax disputes with the IRS,
by conducting outreach and education to taxpayers who speak English as a second language, and by identifying and
advocating for issues that impact low income taxpayers.
The mission statement centers around four goals, which apply to some or all of the clinics, depending on the type of
services provided. The Interim and Year-End reports will require clinics to report on how they are achieving those
goals. To facilitate reporting of the success and achievements of each clinic, the LITC Program Office, in conjunction
with volunteers from various clinics, is developing performance measures. These measures will provide a basis for
clinics in preparing the required Interim and Year-End reports. The LITC Program Office will publish the performance
measures prior to the beginning of the 2011 grant cycle.
Failure to timely submit required reports to the LITC Program Office may result in freezing of funds or termination
of the grant. Under unusual circumstances, clinics may request an extension of time to submit the Interim or Year-End
report. The request must be submitted in writing to the LITC Program Office prior to the due date of the report, and
must include an explanation justifying the extension.
To avoid submitting redundant information in the Year-End report, a clinic may reference parts of the Interim report.
note: Interim and Year-End reports (including the report forms contained in Appendix C) may be released under the
Freedom of Information Act (FOIA). In response to a FOIA request, the LITC Program Office may release these reports after
appropriate redactions to ensure confidentiality of taxpayer information.

26

LOW INCOME TAXPAYER CLINIC

1. INTERIM REPORTS
Interim reports must be submitted to the LITC Program Office by August 1, 2011. The Interim report covers
the first half of the grant cycle ( January 1 through June 30) and consists of an Interim financial report and an
Interim program narrative.

Interim Financial Report
The Interim financial report must contain the following information:
1. A completed Standard Form 425 for the period from January 1, 2011, through June 30, 2011; if additional

space is needed, complete Form 425a. These forms replace Form 269 and are required for all Financial
Report submissions after September 30, 2009.
2. A complete financial narrative, describing how grant funds were expended for the period from January 1,

2011, through June 30, 2011. If the clinic has been awarded funds for both ESL and controversy, a separate financial narrative must be submitted for each program. Note that if miscellaneous or indirect cost
expenses are listed, please explain what is included.
3. A statement whether the clinic will have sufficient matching funds for the remainder of the grant year. The
Program Office recognizes that some clinics may receive some of their matching funds later in the year,
so that grant funds and matching funds may not be evenly spent by the interim mark. Thus, if the clinic’s
Standard Form 425 reflects at the interim mark that the clinic has spent less in matching funds than grant
funds, include sufficient details for the Program Office to ascertain whether the clinic will have sufficient
matching funds for the remainder of the grant year.
Unused funds. If the clinic has not drawn down all of its awarded grant funds by the time the Interim financial
report is due, the clinic must indicate whether it will be drawing down the remainder of its grant award during
the second half of the year. The clinic must also state whether it expects to be deobligating funds and if so, how
much. Also include the reason for the deobligation. If a clinic does not expect to use its entire grant award, it
must contact the LITC Program Office as soon as possible to arrange for a formal release of LITC grant funds
so that the LITC Program Office may reobligate the funds to another LITC prior to September 30th.
Additional funding request. If a clinic needs to request additional funding, it should submit a separate letter
with its Interim report indicating the amount of additional funds being requested and how these funds will be
spent. The clinic’s initial grant award and the amount of additional funding requested for the grant cycle may
not exceed $100,000 (see IRC § 7526(c)(2)).

Interim Program Narrative
The Interim program narrative must contain the following information (numbered in accordance with the
information requested below):
1. A detailed explanation of the strategy used for monitoring and evaluating program results.
2. A description of how program success is defined and measured.
3. A detailed explanation of the progress made in implementing the LITC Program.
4. The status of proposed goals and objectives.

5. A description of any impediments to meeting established goals and objectives, and efforts made to overcome them, if applicable.
6. A description of the clinic’s efforts to publicize the program and the number of individuals reached
through the marketing activities. Include a few examples of publicity such as flyers, brochures, posters,
and newsletters distributed. Other publicity efforts should also be discussed, including radio and television ads, newspaper articles, workshops, outreach events, and visits to other organizations. Please advise
how many times these publicity efforts were utilized (for example, how many times a radio ad ran). Appendix C contains a chart that must be used for tracking publicity and outreach efforts. This form must be
submitted as part of the Interim report.

27

7. A description of the type of representation or other assistance provided to low income taxpayers or ESL

taxpayers, including a list of topics discussed during educational presentations.
8. If applicable, a description of any additional activities, not described previously, through which the clinic

contributed to the community or to improving services for low income and ESL taxpayers. Such activities
include (but are not limited to):
 Training programs (both formal and informal) for other clinics, community groups, service provid-

ers, or other organizations;
 Educating students or employees who go on to provide pro bono assistance to taxpayers, work for

the IRS or other community groups; and
 Serving as a mentor or consultant to other clinics, attorneys, or other organizations.

Please include a discussion of any relevant success stories, but be careful not to include taxpayer identifying information.
9. With respect to any low income taxpayers assisted where the amount in controversy exceeded $50,000,
report the number of such cases. The clinic should maintain documentation in it’s case files of the circumstances surrounding the representation or referral and be prepared to provide this documentation upon
request during site assistance visits. Similarly, for any case accepted where the taxpayer’s income exceeds
250 percent of the Federal Poverty Guidelines, report the number of such cases, and maintain supporting
documentation describing the reason(s) for accepting the case.
10. A completed Supplemental Issue Form, contained in Appendix C of this Publication.

This form

identifies some of the most common tax issues and will help capture the type of assistance provided to
taxpayers. If anything in the form requires an additional explanation, please include this explanation in
the Program Narrative. The clinic may describe cases that involve novel or complex issues. In describing
cases, do not provide taxpayer identifying information.
11. A completed copy of the Interim Report Form (completed for the Interim reporting period), contained

in Appendix C of this Publication. This form is designed to capture the work the clinic has performed
during the first six months of the grant cycle. This form should be filled out completely. Enter N/A if a
category does not apply to the clinic. The numbers contained in the Interim report form are tentative.
At the end of the grant cycle, when the Year-End report form is completed, those numbers are the final
numbers for the 2011 grant cycle. If anything in the form requires an additional explanation, include this
explanation in the Program Narrative.
Note that, alternatively, the clinic may submit the report by e-fax (877-477-3520) or e-mail to
[email protected].

Interim reports should be submitted by August 2, 2011, to the following address:
Internal Revenue Service
Taxpayer Advocate Service
LITC Program Office
Attention: Interim Reports
TA:LITC
Room 1034
1111 Constitution Ave., NW
Washington, DC 20224

28

LOW INCOME TAXPAYER CLINIC

2. YEAR-END REPORTS
Year-End reports must be submitted to the LITC Program Office by March 31, 2012. The Year-End report
covers the entire grant cycle ( January 1 through December 31) and consists of a Year-End financial report and
a Year-End program narrative. For grantees that have been approved for the 2011 grant cycle, failure to submit
the Year-End report for the 2010 grant cycle may result in freezing of grant funds or termination of the grant.

Year-End Financial Report
The Year-End financial report must contain the following information:
1. A completed Standard Form 425 for the period from January 1, 2011, through December 31, 2011; If the

additional space is needed, complete Form 425a. These forms replace the Form 269 and are required for
all Financial Report submissions after September 30, 2009.
2. A breakdown of the actual LITC expenses incurred during the calendar year, including an itemization and

explanation of actual program costs for all expenses. If space was rented for the clinic, provide a breakdown of costs incurred, including rent and insurance. Note that if miscellaneous, other, or indirect cost
expenses are listed, please explain what is included in these line items.
3. The source, date, availability and amount of matching funds received for the LITC Program.
4. In the event any funds over $500 were not obligated, please provide an explanation of why the funds were

not obligated.
note: If the clinic has been awarded funds for both ESL and controversy, a separate statement for items 2, 3, and 4 must be
submitted for each program.

Year-End Program Narrative
The Year-End program narrative must contain the following information (numbered in accordance with the
information requested below):
1. Implementation of the LITC Program.

Describe the strategy for monitoring and evaluating program

results, including how success is defined and measured. In addition, describe the overall approach taken
to implement the LITC Program and the steps taken to ensure compliance with its rules and administrative guidelines. Include a discussion of the clinic’s on-site quality review procedures. (For example,
explain internal procedures used to monitor and evaluate clinic activities to ensure the program was
administered in accordance with grant agreement guidelines).
2. Information Provided to ESL Taxpayers.

Identify how the topics were determined and the type of

analysis that was performed to determine how to best meet the educational needs of the ESL community
the organization serves.
 If written information was developed, identify the reviewer and his or her qualifications.

Identify

the languages other than English in which materials were prepared. If other languages were used,
identify the persons who reviewed the information and their qualifications.
 Identify the methods used to convey information to ESL taxpayers.
 Identify the topics discussed during educational presentations.
3. Training Provided to Students, Volunteers, and LITC Employees.

This includes all training provided

by the clinic, academic institution, or outside sources. Identify the efforts undertaken to ensure students,
volunteers, and LITC employees were adequately prepared to assist taxpayers.
 Describe how training materials were developed and prepared.

Identify who prepared the training

materials, the qualifications of the preparer and how the accuracy of the training materials was verified.
 Describe how the training was provided and the qualifications of the instructor.

29

4. Case Tracking.

Describe the process used to control assignment of controversy cases to students, volun-

teers and LITC employees.
 Describe how you determined to whom the case would be assigned.

Identify the skill levels of the

students, volunteers, and LITC employees in the clinic.
 Describe clinic procedures when the controversy issue exceeds students’, volunteers’, and LITC

employees’ levels of training.
 Describe the type of mentoring program in place to assist students, volunteers, and LITC employ-

ees in resolving controversies.
 Describe the type of monitoring system used to ensure that controversies are resolved expeditiously

and appropriately.
5. Publicity for the LITC.

Describe the clinic’s efforts to publicize the program and the number of individu-

als reached through the marketing activities. Include examples of publicity such as flyers, brochures, posters,
and newsletters distributed. Identify who developed the publicity materials. If publicity materials were
translated into another language, identify who verified the accuracy of the information and their qualifications. Other publicity efforts should also be discussed, including radio and television ads, newspaper articles,
workshops, outreach events, and visits to other organizations. Please advise how many times these publicity
efforts were utilized (for example, how many times a radio ad ran). Appendix C contains a chart that must be
used for tracking publicity and outreach efforts. This form must be submitted as part of the Year-End report.
6. Referral Mechanism for Controversies. Describe the type of referral system that was used to refer tax-

payers with a controversy. Indicate whether follow-up action was performed to determine the outcome
of the controversy or to determine if the referral person/organization was able to assist the taxpayer.
Describe the procedures that were in place to resolve controversies for taxpayers who did not receive appropriate assistance from the referral person/organization.
7. Privacy and Confidentiality.

Describe steps taken to ensure taxpayer privacy and to maintain the confi-

dentiality of tax information.
8. Pro Bono Panel.

Describe the qualified pro bono representatives to whom taxpayers were referred.

Include relevant education and experience of panel members.
9. Nominal Fee. Describe the nominal fee, if any, charged for representing or providing tax information to

taxpayers, including the basis for determining the amount of the nominal fee to be charged.
10. Delivery of Services.

Describe the type of assistance given by telephone and the procedures used to

monitor its quality, if applicable.
11. Program Goals.

Explain whether established goals were met and if goals were not met, the reasons why.

12. Additional Activities.

If applicable, describe any additional activities, not described previously, through

which the clinic contributed to the LITC Program mission, to the community, or to improving services
for low income and ESL taxpayers. Such activities include (but are not limited to):
 Training programs (both formal and informal) for other clinics, community groups, service provid-

ers, or other organizations;
 Educating students or employees who go on to provide pro bono assistance to taxpayers, work for

the IRS, or other community groups; and
 Serving as a mentor or consultant to other clinics, attorneys, or other organizations.

Please include a discussion of any relevant success stories, but be careful not to include taxpayer identifying information.

30

LOW INCOME TAXPAYER CLINIC

13. Last Year in LITC Program.

If you are not continuing in the LITC Program for the 2012 grant cycle,

please detail the steps taken to resolve any open cases or obtain new representation for current clients.
14. Special Orders for Student Practice. Attach copies of the special orders for student practice issued by

the IRS Office of Professional Responsibility, if applicable.
15. With respect to any low income taxpayers assisted where the amount in controversy exceeded

$50,000, report the number of such cases. The clinic should maintain documentation in it’s case files of
the circumstances surrounding the representation or referral and be prepared to provide this documentation upon request during site assistance visits. Similarly, for any case accepted where the taxpayer’s income
exceeds 250 percent of the Federal Poverty Guidelines, report the number of such cases, and maintain
supporting documentation describing the reason(s) for accepting the case.
16. Supplemental Issue Form.

A completed copy of the Supplemental Issue Form contained in Appendix

C of this Publication. This form identifies some of the most common tax issues and helps capture the
type of assistance provided to taxpayers. If anything in the form requires an additional explanation, please
include this explanation in the body of the report. The clinic may describe cases that involve novel or
complex issues. In describing cases, please do not provide taxpayer identifying information.
17. Report Form.

A completed copy of the Report Form, contained in Appendix C of this Publication. This

form is designed to capture the work the clinic has performed during the entire grant cycle. This form
should be filled out completely. The numbers provided in the Year-End report form will be considered
the final numbers for the grant cycle. If anything in the form requires an additional explanation, please
include this explanation in the body of the report.
Note that, alternatively, the clinic may submit the report by e-fax (877-477-3520) or e-mail to
[email protected].
note: LITCs that terminate clinic activity prior to the expiration period of the grant agreement or withdraw from the LITC
Program must submit a final report to the IRS within 90 days of final clinic activity or withdrawal from the program. Similarly, if the LITC Program Office terminates a grant because of a clinic’s failure to comply with the LITC Program requirements,
the clinic must submit a final report within 90 days of the termination.
Subject to OMB approval, the LITC Program Office may require additional reporting information from LITC grantees. Please
refer to www.irs.gov/advocate prior to submitting your application for updates to information reporting requirements.

Year-End Reports should be submitted by March 31, 2012, to the following address:
Internal Revenue Service
Taxpayer Advocate Service
LITC Program Office
Attention: Year-End Reports
TA:LITC
Room 1034
1111 Constitution Ave., NW
Washington, DC 20224

31

V

LITC PROGRAM OFFICE

A. Responsibilities
The LITC Program Office will support and assist LITCs in various ways at the national and local levels including:
 Furthering the clinics’ understanding of the LITC Program and their roles within the Program;
 Assisting with the placement of clinic materials in IRS offices;
 Maintaining Publication 4134 listing all federally funded LITCs and ensuring that the publication is included

in appropriate IRS mailings and mentioned in appropriate IRS publications;
 Informing the public about the availability of LITCs, as appropriate, and to the extent permitted by law,

including references on the IRS Website at www.irs.gov;
 Assisting with clinic marketing efforts to promote the LITC Program;
 Answering questions from potential LITC applicants and current grantees;
 Providing information on how to obtain a special order for student practice from the IRS Office of Profes-

sional Responsibility;
 Coordinating meetings between IRS officials and LITC Program grantees;
 Coordinating and making periodic on-site assistance visits;
 Providing technical assistance, suggestions, recommendations, and guidance to LITCs regarding operation of

their programs;
 Coordinating the cross-functional LITC Program grant application review process;
 Coordinating LITC workgroups;
 Coordinating access to e-services products offered by the IRS; and
 Providing information on how to obtain tax forms and instructions, IRS publications and other pertinent IRS

program materials.

B. Site Assistance Visits
The LITC Program Office will periodically perform on-site assistance visits to selected clinics. Site assistance visits are
a means of providing reliable information to ensure grant funds are being used appropriately and effectively and that
the clinic is complying with the terms and conditions of the LITC grant agreement and Program guidelines. These
visits provide an opportunity to share information about technical issues and identify areas where clinic services can be
improved, and determine what support is needed from the LITC Program Office or other clinics. Site assistance visits
also provide an opportunity for clinic personnel to ask questions and share information about problems they may be
encountering and to identify best practices that can be shared with all clinics.
During site assistance visits, the review process may include reviews of intake procedures, systems for recording referrals of clients, communication and publicity plans, demographics/population information, case statistics and analysis.
In addition, Program Office staff will examine a sampling of expenses to ensure that they are allowable and accurately
reported to the Program Office. Clinics should make documentation regarding expenses available during site visits.
Prior to the assistance visit, the clinic will receive a list of items and topics to be reviewed. Additional items may be
requested during or after the assistance visit. This list may be derived from the standards for clinic operation. As part of
monitoring and evaluating clinic activities, however, the LITC Program Office will be mindful of the clinic’s requirement to protect confidential information.
A site assistance visit generally begins with an opening conference at which the LITC Program Office personnel and
clinic staff discuss the purpose of the visit and the items to be covered. A site assistance visit generally closes with a
conference discussing the results of the visit. The clinic will receive a written report of the visit, including any items
requiring corrective action, generally within 90 days of the visit.
 New Clinics—All new clinics can expect to receive a site assistance visit from the LITC Program Office staff

within the first six months of the grant cycle. Clinics will be contacted prior to the date of the visit to discuss

32

LOW INCOME TAXPAYER CLINIC

specific items that may be reviewed. This initial visit ensures that the clinic is operational and is not experiencing any major difficulties. If the Program Office identifies problems during the initial visit, the Program Office
will schedule an in-depth follow-up visit.
 Returning Clinics—The LITC Program Office strives to conduct a site assistance visit to each clinic at least

once every three years. Prior to a planned visit, the clinic will be notified of the issues and items to be addressed during the visit.
All clinics should receive at least one visit from their Local Taxpayer Advocate (LTA) during the year. This visit is
designed to help foster the relationship between the clinic and its local Taxpayer Advocate Office.
The LITC Program Office may make unscheduled visits during the year.

VI

COMPLETION AND SUBMISSION OF GRANT APPLICATION

A. Where and When to File
Applications may be submitted either electronically or in hard copy by U.S.P.S. mail, private delivery service, or hand
delivery. To submit an electronic application, go to www.grants.gov to apply through the Federal Grants web site. For
applicants applying through the Federal Grants website, the Funding Number is TREAS-GRANTS-052011-001. All
applications (whether submitted electronically or in hard copy) must be postmarked, sent by private delivery service,
hand-delivered to the LITC Program Office in Washington, D.C., or submitted (if filed electronically) byJune 7, 2011,
in order to be considered for 2011 LITC Program grant funding. Applications submitted in hard copy should be sent to
the following address:
Internal Revenue Service
Taxpayer Advocate Service
LITC Program Office
Attention: LITC Applications
TA:LITC
Room 1034
1111 Constitution Ave., NW
Washington, DC 20224
In rare circumstances, the LITC Program Office may grant an extension of the application due date. A request for an
extension must be made in writing to the address above no later than June 9, 2011, and must include an explanation for
the unusual circumstances that prohibited the clinic from meeting the original application due date.
An application may be withdrawn at any time during the application process or prior to the time grant money is
awarded. All withdrawals must be made in writing to the above address.
note: Grant applications may be released in response to Freedom of Information Act (FOIA) requests. Do not include any
taxpayer information in the grant application.

B. LITC Program Grant Application Contents
 Background Information (limited to 15 pages, double-spaced)—This section is designed to solicit in-

formation concerning an organization’s qualifications. Provide specific responses for each of the following
requirements and keep comments concise and relevant. Begin each response by annotating the letter that
corresponds to the appropriate requirement.

33

a. Describe the nature of the organization.

Include a full explanation of existing affiliations with other

organizations, such as schools, governmental bodies, or other charitable organizations.
b. Describe experience in coordinating an LITC Program.

Include type and duration of service, target

groups and geographic areas covered.
c. Describe experience in delivering services to low income and ESL taxpayers.

Include type of service

provided, languages served, number of individuals reached, and geographic area covered.
d. Provide a detailed description of matching funds. Identify committed sources of funding to match the
amount of funding requested. Provide copies of any agreements, memoranda of understanding or similar
documents pertaining to matching funds. Any good faith estimates of matching funds must be accompanied by letters of intent from third parties in an amount equal to the estimated matching funds or a
statement of when such letter of intent or award letter will be granted. For matching funds that consist of
volunteer services, describe how the volunteers’ time is tracked and the rate being used for those services.
e. Describe the organization’s ability to properly spend and account for program funds.

Include examples of

experience in managing federal grants, if any, and a description of the organization’s existing accounting
system and accounting support staff. Include copies of relevant internal accounting procedures, and other
pertinent information. Specifically describe the following:
 Accounting procedures;
 The method for allocating allowable expenses and matching funds between qualifying and non-

qualifying activities or programs, if applicable;
 The plans for audits and controls; and
 The procedures that will be used for proper cost allocation for LITC Program grant funds if the

organization seeks to operate an LITC Program in conjunction with a Volunteer Income Tax Assistance (VITA) Program or a Tax Counseling for the Elderly (TCE) Program.
f. Certify that the applicant is in compliance with its own federal tax responsibilities.

Clinics must be in

compliance with federal tax responsibilities when applying for an LITC grant and also throughout the grant
cycle. To facilitate the resolution of any potential tax compliance issues, we strongly encourage each clinic
that is part of a larger organization (e.g., a university) to submit with its application package a completed
Tax Information Authorization Form. For those clinics that are part of a larger organization, the absence
of a completed form may require additional time to resolve any potential tax compliance issues and could
result in a delay in the receipt of grant funds. A Tax Authorization Form is included in Appendix A.
 Determination of Program Performance (this section is not limited in length)—This section of the applica-

tion is designed to solicit information concerning the ability of a clinic to represent taxpayers, refer taxpayers,
or inform ESL taxpayers about their rights and responsibilities as U.S. taxpayers. Provide specific responses
for each of the following requirements and keep comments concise and relevant. Begin each response by annotating the letter that corresponds to the appropriate requirement.
1. Describe the clinic’s ability to meet the Standards of Operation.

At a minimum, the following questions

must be answered when describing the ability to meet the Standards of Operation:
a. Who is the Qualified Tax Expert (QTE)?

What are the QTE’s qualifications and relevant expertise?

b. Who is the Qualified Business Administrator (QBA)?

What are the QBA’s qualifications and relevant

expertise?
c. Who is the Clinic Director?

What are his or her qualifications and relevant expertise?

d. How much time do those working in the clinic (QTE, QBA, Clinic Director, attorneys, staff, etc.)

spend on clinic activities? How is the time spent tracked?
e. What is the clinic’s publicity and outreach plans, including potential venues for outreach to low

income taxpayers?
f. What is the clinic’s experience in mentoring and providing technical assistance to staff, students, and

volunteers, as well as to other clinics?

34

LOW INCOME TAXPAYER CLINIC

g. What is the clinic’s experience networking with other community-based organizations with which it

can work to reach its target audience?
h. What is the clinic’s accessibility to, and adequacy of, a tax library?

i. What are the qualifications, training, and background of students, volunteers or staff of the clinic? This
includes all training provided by the clinic, academic institution, or outside sources. How will potential
students, volunteers or staff be identified, monitored, and evaluated to ensure taxpayers receive accurate
assistance?
j. What are the continuing professional educational (CPE) activities of the clinic staff and volunteers?

k. Describe the clinic’s pro bono network referral panel. How are panel members recruited and what are
the procedures for monitoring and following up on referrals?
2. Provide background information on quality of management staff.

List the titles, responsibilities and quali-

fications of the top five members of professional staff who will be involved with the LITC Program.
3. Describe the proposed program plan. The plan should not be limited to what has been done in the past

or to existing programs. Include a description of the type of assistance (Controversy or ESL) that will be
provided if an award is granted. Provide a detailed description of the program goals. If the program goals
extend beyond one year, state goals by annual increments of up to three years. If the clinic will be providing both Controversy and ESL services, submit a separate program plan and goals for each.
4.

Explain internal procedures for monitoring and evaluating clinic activities to ensure the program is administered in accordance with eligibility guidelines and that grant funds are used for program purposes. The
following procedures must also be explained in this section, if applicable:
a. Plans for tracking the 90/250 income requirement;

b. Plans for tracking the amount in controversy for any taxable year generally does not exceed the
amount specified in IRC § 7463 (currently $50,000);
c. Plans for monitoring the effectiveness of programs designed to inform ESL taxpayers about their
taxpayer rights and responsibilities and efforts planned to reach the targeted audience;
d. Plans for charging nominal fees, if any (and the amount); and,
e. Plans for tracking the number of ESL taxpayers served.

5.

Identify geographic area(s) the clinic will serve. This includes a breakdown of the counties served by the
clinic. Identify the number of ESL taxpayers in the geographic area the clinic will serve. Also identify any
languages in which the clinic provides interpreter assistance. Clarify if interpreters are available.

6.

Include dates, days and hours of clinic operation. All clinics must indicate whether the clinic will be open
full-time and year-round. Year-round, full-time access is preferable to part-time or partial year access for
clients. In making grant awards, consideration will be given to whether clinics are open full-time and yearround. Describe plans for staffing the LITC during periods of student absences if the LITC is part of an
academic organization.

note: If the clinic is awarded a grant premised on operating full-time and year-round and later changes the operating schedule,
the LITC Program Office may make a reduction in funding during the year.
7.

Describe plans to protect taxpayer privacy and to maintain confidentiality of taxpayer information and
any tax returns prepared.

8.

Describe the strategy for monitoring and evaluating program results (in short and long-term), including
how success will be defined and measured.

35

9.

Describe plans, if any, to make name or organizational changes. Requests to approve name or organizational
status changes must be submitted in writing to the LITC Program Office in advance of the effective dates
of proposed changes with sufficient time to afford program evaluation and legal review. Supplemental
information may be required. Supplemental information may include, but is not limited to, certifications
by the clinic’s legal counsel that transfers were properly effected under applicable laws and evidence that a
successor-in-interest is eligible to perform the grant and will comply with all the terms of the grant, including
the program plan. IRS approval criteria will include, but is not limited to, the statutory requirements of IRC
§ 7526. The statutory requirements include, but are not limited to, the limitation that the aggregate amount
of grants which may be made to a clinic for a year shall not exceed $100,000 (see IRC § 7526(c)(2)).

 Civil Rights Requirements—This section describes the data collection and reporting requirements required

of LITC grant applicants by the IRS to meet its responsibilities pursuant to Title VI of the Civil Rights Act of
1964, as amended, which prohibits discrimination on the basis of race, color, or national origin in any program
or activity receiving federal funds; Title IX of the Education Amendments of 1972, as amended, which prohibits discrimination on the basis of sex in any education program or activity receiving federal funds; § 504 of the
Rehabilitation Act of 1973, as amended, which prohibits discrimination on the basis of disability in any program or activity receiving federal funds; and the Age Discrimination Act of 1975, as amended, which prohibits
discrimination on the basis of age in any program or activity receiving federal funds.
1.

A list of active lawsuits or complaints naming the applicant which allege discrimination on the basis of race,
color, national origin, age, sex, or disability with respect to service or benefits being provided. The list should
include: the date the lawsuit or complaint was filed; a summary of the allegation; and the status of the lawsuit or complaint, including whether the parties to a lawsuit have entered into a consent decree.

2.

A description of all pending applications for financial assistance and all financial assistance currently provided by other federal agencies. For all applicants for IRS financial assistance, this information should be
relevant to the organizational entity actually submitting the application, not necessarily the larger agency
or department of which the entity is a part.

3. A summary of all civil rights compliance review activities conducted in the last three years. The summary
shall include: the purpose or reason for the review; a summary of the findings and recommendations of
the review; and a report on the status or disposition of such findings and recommendations. For all applicants for IRS financial assistance, this information should be relevant to the organizational entity actually
submitting the application, not necessarily the larger agency or department of which the entity is a part.
note: Responses to these civil rights questions must be directly related to the clinic and not the sponsoring organization. If the
clinic does not have any information to report on these questions, a negative response is required.
 Budget/Financial Information—This section is designed to solicit information concerning an organization’s

budget request for the grant cycle. Provide the requested forms or information listed below. Organizations
providing Controversy and ESL services must submit a separate budget for each program.
1. Standard Form 424A, Budget Information – Non-Construction Programs (one for each qualifying program (Controversy and ESL), if applicable).
2. Budget narrative (one for each qualifying (Controversy and ESL) program, if applicable). The budget
narrative should explain the expenses stated on Standard Form 424A.
3. Copy of most recent audited or unaudited financial statement. If an unaudited financial statement is
submitted, please explain why an audited financial statement is not available. If a financial statement is not
available, please include a profit and loss statement.
4.

36

Copy of most recent A-133 Audit with findings, if applicable.

LOW INCOME TAXPAYER CLINIC

C. General Instructions For Submission Of LITC Program Grant Application Packages
If the application is not submitted electronically, the Application Package must be assembled as described below and
submitted in quadruplicate (four sets). The LITC Program Office will provide a copy of your Application Package to
the IRS EEO Office, for a pre-award civil rights compliance review. All application documents must be typed and numbered at the bottom of the page. All documents (originals and three copies) must have original signatures in blue ink.
note: If your multi-year grant cycle has ended, you must submit a complete new application. However, if your multi-year
grant has not ended, an application will be required, but it is not as extensive as an application for a new clinic or a clinic that
chooses to reapply each year without seeking a multi-year grant, as detailed below.
If the clinic is a continuing clinic and wishes to switch its designation (e.g., in 2010 the clinic is providing controversy services,
but in 2011 the clinic will be providing controversy and ESL services), a complete new application must be submitted.

LITC PROGRAM GRANT APPLICATION PACKAGE ASSEMBLY
It is very important that the LITC Program grant application package be assembled correctly. An improperly assembled or incomplete application will cause a delay in processing and may result in rejection of the application. A
copy of IRS Form 12183, Grant Agreement, included in Appendix A, is for information only and is not required to be
submitted with the package. Once a grant has been awarded, a clinic will receive a completed Form 12183 to sign and
accept the award. A checklist is provided in Appendix B to assist in assembling the package in the correct order. The
application package should be assembled in the following manner:

1.

Standard Form 424, Application for Federal Assistance: completed according to instructions provided with the
form and signed and dated in blue ink (not a photocopy) by an authorized representative of the organization.
Check the box on Line 21, indicating agreement to the various certifications and assurances. The LITC Program
Catalog of Federal Domestic Assistance Number, Block #10, is 21.008.

NOTE: In Box 5, the organization’s legal name should be shown in the space provided. The clinic’s name (if different from the organization’s legal name) should be placed in the space designated for the “Organizational Unit.”

2.

note: For a continuing multi-year grant application, check “continuation” in Block 8, Type of Application.
Background Information prepared according to instructions (page 35).

note: For a continuing multi-year grant application, in lieu of a background narrative, include a letter requesting
continuation in the LITC Program for the 2011 grant cycle. The letter must include the grant amount requested for
the 2011 grant cycle and any proposed program modifications to the original application.

3.

Copy of the determination letter issued by IRS recognizing organization as exempt under IRC § 501(c), if ap-

4.

Copy of letter of academic accreditation for affiliated college, university or other institution of higher learning,

5.

Determination of Program Performance prepared according to instructions (one for each qualifying program,

6.

Budget/Financial Information prepared according to instructions (one for each qualifying program, if applica-

7.

Provide a detailed description of matching funds. Identify committed sources of funding to match the amount

plicable. (Not necessary for a continuing multi-year grant application.)
if applicable. (Not necessary for a continuing multi-year grant application.)
if applicable) (page 36). (Not necessary for a continuing multi-year grant application.)
ble) (page 35).
of funding requested. Provide copies of any agreements, memoranda of understanding or similar documents
pertaining to matching funds. Any good faith estimates of matching funds must be accompanied by letters of
intent from third parties in an amount equal to the estimated matching funds or a description of when such
letter of intent or award letter will be granted.

8.

For a continuing multi-year grant application, an estimate of funds that will not be expended during the 2010
grant cycle and the reasons the funds will not be used.

37

9.

Completed Form 13424, IRS Low Income Taxpayer Clinic (LITC) Application Information Sheet. The form
is included in Appendix A of this package.

10. Civil Rights Statement as described in Section IV, D;

11.

12. Tax Information Authorization Form, if applicable.

note: Attachments must be assembled in the order listed above and must be signed and dated in blue ink.

Standard Form LLL, Disclosure of Lobbying Activities (required by 31 CFR 21.100(c)); and

VII

SELECTION AND AWARD OF GRANT RECIPIENTS

Throughout the selection and award decision-making process, the IRS seeks to provide grants to qualified organizations, including academic institutions and nonprofit organizations throughout the United States, for low income
representation and ESL tax educational services.
The IRS may award grants with one-year, two-year, and three-year project periods to clinics evaluated under this application cycle’s selection and award process. Clinics awarded a two or three-year grant based on acceptance of their program
plans will not undergo formal evaluation under the second or third year cycle selection and award process. However, two
and three-year recipients will be reviewed annually for satisfactory performance and progress in meeting goals and objectives as well as compliance with grant terms. The funding level for subsequent years will be reviewed annually and may
be increased or decreased at the discretion of the LITC Program Office. All funding will be based on the availability of
annually appropriated funds. Awarding of multi-year grants is at the discretion of the LITC Program Office.
All applications will undergo a preliminary eligibility screening. Applications that do not meet all eligibility screening
criteria will be eliminated from the award process. Applications that pass the eligibility screening will then be evaluated
based on their Technical Merit, Amount of Funding Requested, and Other Considerations.

A. Eligibility Screening
Applications will be reviewed to determine the following information:
 Length of Grant Requested (one-year, two-year or three-year);
 Type of Service Proposed (Controversy, ESL, or both); and
 Status of Organization (previous recipient of an LITC grant, start-up or other).

Applications will be reviewed further to determine if all required items are included in the application package. Please
be sure to use the checklist in Appendix B to ensure all required items are included.

B. Evaluation Process
Applications that pass the eligibility screening process will undergo a two-tiered evaluation process. Applications will be
subject to both a technical evaluation and a secondary evaluation. The IRS retains discretionary authority to award grant
funds based on controversy, ESL or a combination of program plans to achieve the four goals of the LITC Program.

1. TECHNICAL EVALUATION
During the technical evaluation, each application will be awarded points in each of the areas listed below
based on the information contained in their proposed program plan(s). Each criterion reflects the maximum
number of points that may be assigned in that category. In assigning numerical points, the IRS will evaluate
the program plan based on how it will assist in accomplishment of the LITC Program mission and goals as
stated elsewhere in the application package. Organizations can receive a maximum of 100 points.

38

LOW INCOME TAXPAYER CLINIC

If the clinic is applying for funds to provide a combination of controversy and ESL services, separate program
plans must be submitted, and each program plan will be evaluated separately. Points will be assigned as follows:


Quality of programs offered to assist low income taxpayers or ESL taxpayers. This item evaluates the qualifications of administrators and qualifications and tax expertise of qualified representatives; comprehensiveness
of the services to be provided; amount of time devoted to the program by clinic staff; quality of training and
technical support to clinic volunteers, students, and LITC employees; plans for supervising clinic volunteers,
students, and LITC employees; procedures for ensuring the confidentiality of taxpayer information; publicity
of clinic operations; and the dates and days and hours of clinic operation. (Maximum 75 points).



Experience in sponsoring a tax clinic where individuals with tax controversies with the IRS were represented, or experience in sponsoring a tax clinic where taxpayers with tax controversies with the IRS were
referred to a pro bono panel of qualified representatives, or experience in providing a program to inform
ESL taxpayers about their taxpayer rights and responsibilities. (Maximum 10 points).



Quality of grant administration and internal accounting procedures. (Maximum 10 points).



Number of low income or ESL taxpayers in geographic area and proposed efforts to reach these taxpayers.
(Maximum 5 points).

2. PROGRAM OFFICE EVALUATION
After the completion of the technical evaluation, applications will undergo a secondary review by the LITC
Program Office. This evaluation will be based on the information contained in the program plan, as well as the
clinic’s history in the LITC Program (if the clinic is a returning clinic). Specifically, the evaluation will look at:


New Applicants. The LITC Program Office will perform a general review of the application and program
plan to ensure that the clinic has sufficient funds, can meet the program requirements, and that the technical review did not raise any significant concerns.



Returning and Multi-Year Applicants. The LITC Program Office will perform a general review of the
application and program plan, as well as a more detailed review of the clinic’s history in the LITC Program. The Program Office will look at:
1.

Timeliness and completeness of Interim and Year-End reports;

2.

Any significant concerns raised by prior site assistance visits and whether the clinic has addressed
those concerns;

3.

Whether the clinic’s activities match its program plan;

4.

Clinic’s involvement with other clinics, community groups, Taxpayer Advocate Service (TAS), and
the LITC Program Office;

5.

Whether the clinic has a history of not drawing down funds timely; and

6. Whether the clinic has failed to notify the LITC Program Office of any unused funds in sufficient time
for the Program Office to reobligate them to another clinic.
All applicants will also undergo a review of the organization’s federal tax compliance status. Grant funds
may be withheld or denied based on an applicant’s failure to be in full compliance with all current federal
tax obligations.
The decision of whether or not to award grant funds will be based on the technical evaluation, Program Office
evaluation, and the following additional considerations:
 To foster parity regarding clinic availability and accessibility for low income and ESL taxpayers nationwide,

the LITC Program Office will consider the geographic areas of applicants and the languages in which the
applicants will assist taxpayers. To better identify areas most in need of LITC services, the Program Office
has completed an evaluation of areas serviced by existing LITCs. Based on the findings of this assessment, the
LITC Program Office is accepting applications for the 2011 grant cycle, with an emphasis on the following
types of organizations: (1) organizations currently receiving a grant for the 2010 grant cycle, and (2) organizations not currently receiving a grant cycle in the following counties:

39

Admissible Areas for New Clinic Applications
STATE

COUNTY

STATE

COUNTY

CA

Kern

NC

Guilford

CA

Stanislaus

NC

Wake

CA

Ventura

NY

Orange

CA

San Bernardino

OH

Summit

CA

Riverside

OH

Montgomery

CA

Placer

OH

Mahoning

CA

Sacramento

OH

Trumbull

CA

Santa Clara

PA

Mercer

CA

San Joaquin

PA

Lehigh

CO

El Paso

PA

Northampton

CT

Fairfield

PA

Dauphin

FL

Lee

PA

Cumberland

FL

Volusia

PA

Lackawanna

FL

Polk

PA

Luzerne

FL

Orange

SC

Charleston

FL

Brevard

TN

Hamilton

FL

Manatee

TX

Travis

GA-SC

Augusta-Richmond

TX

Williamson

IL

St. Clair

TX

Hidalgo

MA

Worcester

UT

Weber

MI

Kent

VA

City of Virginia Beach

MO

St. Louis

WI

Dane

 If applications from more than one clinic sponsored by the same institution or organization are received, the

LITC Program will consider all factors surrounding the operation of the clinics, including the geographic areas
served by the clinics and the comprehensiveness of the services to be provided, in determining whether and in
what amount grants will be made to one or more such clinics.
 For academic clinics, which generally serve fewer taxpayers than nonacademic clinics because of the time

involved in teaching and mentoring students, the LITC Program will consider additional ways in which academic clinics can accomplish LITC Program goals (e.g., providing technical assistance, training, and mentoring to other LITC programs, publishing articles about the LITC Program, commenting on proposed Treasury
regulations that affect low income or ESL taxpayers, and monitoring graduates to determine whether they
perform pro bono work on behalf of or otherwise assist low income taxpayers).
 The number of taxpayers who will be served by the clinic, including the ESL taxpayers in the geographic area

and the languages served by the clinic.
 The existence of other LITC Programs serving the same population.
 Appropriateness of funds sought for quantity and quality of services to be offered.
 Other sources of funding available to the clinic.

C. Notification Of Award Decisions
The LITC Program Office will notify organizations of their acceptance or rejection of their grant application no later than
November 27, 2010. Accepted organizations will be provided the name, address and telephone number of the Program Office analyst assigned to your geographic area after the Form 12183, Grant Agreement, is signed. The LITC Program Office
may, at its discretion, conduct a site inspection visit to a prospective LITC Program location prior to awarding grant funds.

40

LOW INCOME TAXPAYER CLINIC

APPENDIX A

LITC Program Grant Forms

41

APPENDIX A
OMB Number: 4040-0004
Expiration Date: 01/31/2009

Version 02

Application for Federal Assistance SF-424
* 1. Type of Submission:

* 2. Type of Application:

Preapplication

New

Application

Continuation

Changed/Corrected Application

Revision

* 3. Date Received:

* If Revision, select appropriate letter(s):

* Other (Specify)

4. Applicant Identifier:

5a. Federal Entity Identifier:

* 5b. Federal Award Identifier:

State Use Only:
6. Date Received by State:

7. State Application Identifier:

8. APPLICANT INFORMATION:
* a. Legal Name:
* b. Employer/Taxpayer Identification Number (EIN/TIN):

* c. Organizational DUNS:

d. Address:
* Street1:
Street2:
* City:
County:
* State:
Province:
* Country:

USA: UNITED STATES

* Zip / Postal Code:

e. Organizational Unit:
Department Name:

Division Name:

f. Name and contact information of person to be contacted on matters involving this application:
Prefix:

* First Name:

Middle Name:
* Last Name:
Suffix:
Title:
Organizational Affiliation:

* Telephone Number:
* Email:

42

LOW INCOME TAXPAYER CLINIC

Fax Number:

OMB Number: 4040-0004
Expiration Date: 01/31/2009

Application for Federal Assistance SF-424

Version 02

9. Type of Applicant 1: Select Applicant Type:

Type of Applicant 2: Select Applicant Type:

Type of Applicant 3: Select Applicant Type:

* Other (specify):

* 10. Name of Federal Agency:

11. Catalog of Federal Domestic Assistance Number:

CFDA Title:

* 12. Funding Opportunity Number:

* Title:

13. Competition Identification Number:

Title:

14. Areas Affected by Project (Cities, Counties, States, etc.):

* 15. Descriptive Title of Applicant's Project:

Attach supporting documents as specified in agency instructions.

43

OMB Number: 4040-0004
Expiration Date: 01/31/2009

Version 02

Application for Federal Assistance SF-424
16. Congressional Districts Of:
* a. Applicant

* b. Program/Project

Attach an additional list of Program/Project Congressional Districts if needed.

17. Proposed Project:
* a. Start Date:

* b. End Date:

18. Estimated Funding ($):
* a. Federal
* b. Applicant
* c. State
* d. Local
* e. Other
* f. Program Income
* g. TOTAL

* 19. Is Application Subject to Review By State Under Executive Order 12372 Process?
.

a. This application was made available to the State under the Executive Order 12372 Process for review on
b. Program is subject to E.O. 12372 but has not been selected by the State for review.
c. Program is not covered by E.O. 12372.
* 20. Is the Applicant Delinquent On Any Federal Debt? (If "Yes", provide explanation.)

Yes

No

21. *By signing this application, I certify (1) to the statements contained in the list of certifications** and (2) that the statements
herein are true, complete and accurate to the best of my knowledge. I also provide the required assurances** and agree to
comply with any resulting terms if I accept an award. I am aware that any false, fictitious, or fraudulent statements or claims may
subject me to criminal, civil, or administrative penalties. (U.S. Code, Title 218, Section 1001)

** I AGREE
** The list of certifications and assurances, or an internet site where you may obtain this list, is contained in the announcement or agency
specific instructions.

Authorized Representative:
Prefix:

* First Name:

Middle Name:
* Last Name:
Suffix:
* Title:
* Telephone Number:

Fax Number:

* Email:
* Signature of Authorized Representative:
Authorized for Local Reproduction

* Date Signed:
Standard Form 424 (Revised 10/2005)
Prescribed by OMB Circular A-102

44

LOW INCOME TAXPAYER CLINIC

APPENDIX A
OMB Number: 4040-0004
Expiration Date: 01/31/2009

Application for Federal Assistance SF-424

Version 02

* Applicant Federal Debt Delinquency Explanation
The following field should contain an explanation if the Applicant organization is delinquent on any Federal Debt. Maximum number of
characters that can be entered is 4,000. Try and avoid extra spaces and carriage returns to maximize the availability of space.

45

APPENDIX A
INSTRUCTIONS FOR THE SF-424
Public reporting burden for this collection of information is estimated to average 60 minutes per response, including time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the
Office of Management and Budget, Paperwork Reduction Project (0348-0043), Washington, DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET. SEND IT TO THE ADDRESS
PROVIDED BY THE SPONSORING AGENCY.

This is a standard form (including the continuation sheet) required for use as a cover sheet for submission of preapplications and applications and
related information under discretionary programs. Some of the items are required and some are optional at the discretion of the applicant or the
Federal agency (agency). Required items are identified with an asterisk on the form and are specified in the instructions below. In addition to the
instructions provided below, applicants must consult agency instructions to determine specific requirements.
Item
1.

2.

Entry:
Type of Submission: (Required): Select one type of submission in
accordance with agency instructions.
• Preapplication
• Application
• Changed/Corrected Application – If requested by the agency, check if this
submission is to change or correct a previously submitted application. Unless
requested by the agency, applicants may not use this to submit changes after
the closing date.

Item
10.

Entry:
Name Of Federal Agency: (Required) Enter the name of
the Federal agency from which assistance is being
requested with this application.

11.

Type of Application: (Required) Select one type of application in accordance
with agency instructions.

12.

Catalog Of Federal Domestic Assistance Number/Title:
Enter the Catalog of Federal Domestic Assistance number
and title of the program under which assistance is
requested, as found in the program announcement, if
applicable.
Funding Opportunity Number/Title: (Required) Enter the
Funding Opportunity Number and title of the opportunity
under which assistance is requested, as found in the
program announcement.
Competition Identification Number/Title: Enter the
Competition Identification Number and title of the
competition under which assistance is requested, if
applicable.

• New – An application that is being submitted to an agency for the first time.
• Continuation - An extension for an additional funding/budget period for a
project with a projected completion date. This can include renewals.
• Revision - Any change in the Federal Government’s financial obligation or
contingent liability from an existing obligation. If a
revision, enter the appropriate letter(s). More than one may be
selected. If "Other" is selected, please specify in text box provided.
A. Increase Award
B. Decrease Award
C. Increase Duration
D. Decrease Duration
E. Other (specify)

3.

Date Received: Leave this field blank. This date will be assigned by the
Federal agency.

4.

Applicant Identifier: Enter the entity identifier assigned buy the Federal
agency, if any, or the applicant’s control number if applicable.

5a.

Federal Entity Identifier: Enter the number assigned to your
organization by the Federal Agency, if any.

5b.

Federal Award Identifier: For new applications leave blank. For a
continuation or revision to an existing award, enter the previously assigned
Federal award identifier number. If a changed/corrected application, enter the
Federal Identifier in accordance with agency instructions.
Date Received by State: Leave this field blank. This date will be assigned by
the State, if applicable.

6.
7.

State Application Identifier: Leave this field blank. This identifier will be
assigned by the State, if applicable.

8.

Applicant Information: Enter the following in accordance with agency
instructions:
a. Legal Name: (Required): Enter the legal name of applicant that will
undertake the assistance activity. This is ththat the organization has
registered with the Central Contractor Registry. Information on registering with
CCR may be obtained by visiting the Grants.gov website.
b. Employer/Taxpayer Number (EIN/TIN): (Required): Enter the Employer
or Taxpayer Identification Number (EIN or TIN) as assigned by the Internal
Revenue Service. If your organization is not in the US, enter 44-4444444.

46

LOW INCOME TAXPAYER CLINIC

13.

14.

15.

16.

Areas Affected By Project: List the areas or entities using
the categories (e.g., cities, counties, states, etc.) specified in
agency instructions. Use the continuation sheet to enter
additional areas, if needed.
Descriptive Title of Applicant’s Project: (Required) Enter
a brief descriptive title of the project. If appropriate, attach a
map showing project location (e.g., construction or real
property projects). For preapplications, attach a summary
description of the project.
Congressional Districts Of: (Required) 16a. Enter the
applicant’s Congressional District, and 16b. Enter all
District(s) affected by the program or project. Enter in the
format: 2 characters State Abbreviation – 3 characters
District Number, e.g., CA-005 for California 5th district, CA012 for California 12th district, NC-103 for North Carolina’s
103rd district. • If all congressional districts in a state are
affected, enter “all” for the district number, e.g., MD-all for all
congressional districts in Maryland. • If nationwide, i.e. all
districts within all states are affected, enter US-all. • If the
program/project is outside the US, enter 00-000.

17.

Proposed Project Start and End Dates: (Required) Enter
the proposed start date and end date of the project.

18.

Estimated Funding: (Required) Enter the amount
requested or to be contributed during the first funding/budget
period by each contributor. Value of in-kind contributions
should be included on appropriate lines, as applicable. If the
action will result in a dollar change to an existing award,
indicate only the amount of the change. For decreases,
enclose the amounts in parentheses.

c. Organizational DUNS: (Required) Enter the organization’s DUNS or
DUNS+4 number received from Dun and Bradstreet. Information on obtaining
a DUNS number may be obtained by visiting the Grants.gov website.

19.

d. Address: Enter the complete address as follows: Street address (Line 1
required), City (Required), County, State (Required, if country is US),
Province, Country (Required), Zip/Postal Code (Required, if country is US).

20.

e. Organizational Unit: Enter the name of the primary organizational unit
(and department or division, (if applicable) that will undertake the assistance
activity, if applicable.

21.

f. Name and contact information of person to be contacted on matters
involving this applicat required), organizational affiliation (if affiliated with an
organization other on: Enter the name (First and last name than the applicant
organization), telephone number (Required), fax number, and email address
(Required) of the person to contact on matters related to this application.

9.

Is Application Subject to Review by State Under
Executive Order 12372 Process? Applicants should
contact the State Single Point of Contact (SPOC) for Federal
Executive Order 12372 to determine whether the application
is subject to the State intergovernmental review process.
Select the appropriate box. If “a.” is selected, enter the date
the application was submitted to the State.
Is the Applicant Delinquent on any Federal Debt?
(Required) Select the appropriate box. This question applies
to the applicant organization, not the person who signs as
the authorized representative. Categories of debt include
delinquent audit disallowances, loans and taxes. If yes,
include an explanation on the continuation sheet.
Authorized Representative: (Required) To be signed and
dated by the authorized representative of the applicant
organization. Enter the name (First and last name required)
title (Required), telephone number (Required), fax number,
and email address (Required) of the person authorized to
sign for the applicant. A copy of the governing body’s
authorization for you to sign this application as the official
representative must be on file in the applicant’s office.
(Certain Federal agencies may require that this
authorization be submitted as part of the application.)

Type of Applicant: (Required) Select up to three applicant type(s) in
accordance with agency instructions.
M. Nonprofit
A. State Government
N. Nonprofit
B. County Government
O. Private Institution of
C. City or Township
Higher Education
Government
P. Individual
D. Special District Government
Q. For-Profit Organization
E. Regional Organization
(Other than Small
F. U.S. Territory or Possession
Business)
G. Independent School District
R. Small Business
H. Public/State Controlled
S. Hispanic-serving
Institution of Higher
Institution
Education
T. Historically Black
I.
Indian/Native American
Colleges and
Tribal Government
Universities (HBCUs)
(Federally Recognized)
U. Tribally Controlled
J. Indian/Native American
Colleges and
Tribal Government (Other
Universities (TCCUs)
than Federally Recognized)
V. Alaska Native and
K. Indian/Native American
Native Hawaiian Serving
Tribally Designated
Institutions
Organization
W. Non-domestic (non-US)
L. Public/Indian Housing
Entity
Authority
X. Other (specify)

47

In addition to the Instructions for SF-424, please pay close attention to the following lines:
Line 2

 Check the “New” box when the organization is a new applicant, a returning applicant that does
not have a multi-year grant, or an applicant applying for year one of a multi-year grant.
 Check the “Continuation” box when applying for year two or three of a multi-year grant.

Line 4 through Line 7

Leave blank

Line 8a

Name of Sponsoring Organization

Line 8b

Employer Identification Number (Do not list a Social Security Number)

Line 8c

Organizational DUNS - This is required for all organizations that receive grant funds. This number
is assigned by the Dunn & Bradstreet organization. The website link to apply for a DUNS number is:
http://smallbusiness.dnb.com/establish-your-business/12334338-1.html

Line 8d

Address of Sponsoring Organization

Line 8e, 9

Leave blank

Line 10

Internal Revenue Service

Line 11

CFDA Number - 21.008
CFDA Title - Low Income Taxpayer Clinic

Line 12

Funding Opportunity Number-TREAS-GRANTS-052011-001
Title - Low Income Taxpayer Clinic

Line 13

Leave blank

Line 14

List the counties your LITC will be primarily serving

Line 15

Specify “Low Income Taxpayer Clinic”

Line 17

If you are applying for a one-year grant, or are entering year two or year three of an approved multiyear grant, the “start date” is 1/1/2011 and the “end date” is 12/31/2011. If you are applying for year
one of a multi-year grant, the “start date” is 1/1/2011 and the “end date” is 12/31/2012 (for a two-year
grant) or 12/31/2013 (for a three-year grant).

Line 18a

This is the total amount of grant funds being requested for a one-year grant or the total for a multiyear grant. Remember that in any single year, the maximum amount of a grant the IRS may award is
$100,000.

Line 18b

The amount of matching funds from all sources the organization intends to have.

Line 18c, 18d, 18e

Leave blank

Line 18f

Any program income for the organization

Line 18g

Total of lines 18a and18f. Include the total on Line 18.

Line 19

Leave blank

48

LOW INCOME TAXPAYER CLINIC

APPENDIX A
BUDGET INFORMATION - Non-Construction Programs
Grant Program
Function
or Activity
(a)

Catalog of Federal
Domestic Assistance
Number
(b)

1.

OMB Approval No. 0348-0044

SECTION A - BUDGET SUMMARY

Estimated Unobligated Funds

$

Federal
(c)

$

New or Revised Budget

Non-Federal
(d)

$

Federal
(e)

$

Non-Federal
(f)

$

Total
(g)
0.00

2.

0.00

3.

0.00

4.
5.

0.00

Totals

$

0.00

$

0.00

$

0.00

$

0.00

$

0.00

SECTION B - BUDGET CATEGORIES
6. Object Class Categories
a. Personnel

GRANT PROGRAM, FUNCTION OR ACTIVITY
(1)

(2)

$

(3)

$

$

Total

$

$

(5)

0.00

b. Fringe Benefits

0.00

c. Travel

0.00

d. Equipment

0.00

e. Supplies

0.00

f. Contractual

0.00

g. Construction

0.00

h. Other

0.00

i. Total Direct Charges (sum of 6a-6h)

0.00

0.00

0.00

0.00

0.00

j. Indirect Charges
k. TOTALS (sum of 6i and 6j)
7. Program Income

0.00

$

$

0.00

$

$

0.00

$

$

Authorized for Local Reproduction
Previous Edition Usable

0.00

$

$

0.00

$

$

0.00
0.00

Standard Form 424A (Rev. 7-97)
Prescribed by OMB Circular A-102

49

APPENDIX A

SECTION C - NON-FEDERAL RESOURCES
(b) Applicant
(c) State

(a) Grant Program
8.

$

$

(d) Other Sources
$

(e) TOTALS
$

0.00

9.

0.00

10.

0.00

11.

0.00

12. TOTAL (sum of lines 8-11)

$

0.00 $

0.00 $

0.00

$

0.00

SECTION D - FORECASTED CASH NEEDS
Total for 1st Year

13. Federal

$

14. Non-Federal

1st Quarter

0.00 $

2nd Quarter

3rd Quarter

$

$

0.00 $

0.00 $

4th Quarter

$

0.00

15. TOTAL (sum of lines 13 and 14)

$

0.00 $

0.00

0.00

$

SECTION E - BUDGET ESTIMATES OF FEDERAL FUNDS NEEDED FOR BALANCE OF THE PROJECT
(a) Grant Program
16.

FUTURE FUNDING PERIODS (Years)
(c) Second
(d) Third

(b) First
$

$

$

$

0.00 $

0.00 $

(e) Fourth
$

17.
18.
19.
20. TOTAL (sum of lines 16-19)

0.00

$

0.00

SECTION F - OTHER BUDGET INFORMATION
21. Direct Charges:

22. Indirect Charges:

23. Remarks:
Authorized for Local Reproduction

50

LOW INCOME TAXPAYER CLINIC

Standard Form 424A (Rev. 7-97) Page 2

INSTRUCTIONS FOR THE SF-424
Public reporting burden for this collection of information is estimated to average 60 minutes per response, including time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the
Office of Management and Budget, Paperwork Reduction Project (0348-0043), Washington, DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET. SEND IT TO THE ADDRESS
PROVIDED BY THE SPONSORING AGENCY.

This is a standard form (including the continuation sheet) required for use as a cover sheet for submission of preapplications and applications and
related information under discretionary programs. Some of the items are required and some are optional at the discretion of the applicant or the
Federal agency (agency). Required items are identified with an asterisk on the form and are specified in the instructions below. In addition to the
instructions provided below, applicants must consult agency instructions to determine specific requirements.
Item
1.

2.

Entry:
Type of Submission: (Required): Select one type of submission in
accordance with agency instructions.
• Preapplication
• Application
• Changed/Corrected Application – If requested by the agency, check if this
submission is to change or correct a previously submitted application. Unless
requested by the agency, applicants may not use this to submit changes after
the closing date.

Item
10.

Entry:
Name Of Federal Agency: (Required) Enter the name of
the Federal agency from which assistance is being
requested with this application.

11.

Type of Application: (Required) Select one type of application in accordance
with agency instructions.

12.

Catalog Of Federal Domestic Assistance Number/Title:
Enter the Catalog of Federal Domestic Assistance number
and title of the program under which assistance is
requested, as found in the program announcement, if
applicable.
Funding Opportunity Number/Title: (Required) Enter the
Funding Opportunity Number and title of the opportunity
under which assistance is requested, as found in the
program announcement.
Competition Identification Number/Title: Enter the
Competition Identification Number and title of the
competition under which assistance is requested, if
applicable.

• New – An application that is being submitted to an agency for the first time.
• Continuation - An extension for an additional funding/budget period for a
project with a projected completion date. This can include renewals.
• Revision - Any change in the Federal Government’s financial obligation or
contingent liability from an existing obligation. If a
revision, enter the appropriate letter(s). More than one may be
selected. If "Other" is selected, please specify in text box provided.
A. Increase Award
B. Decrease Award
C. Increase Duration
D. Decrease Duration
E. Other (specify)

3.

Date Received: Leave this field blank. This date will be assigned by the
Federal agency.

4.

Applicant Identifier: Enter the entity identifier assigned buy the Federal
agency, if any, or the applicant’s control number if applicable.

5a.

Federal Entity Identifier: Enter the number assigned to your
organization by the Federal Agency, if any.

5b.

Federal Award Identifier: For new applications leave blank. For a
continuation or revision to an existing award, enter the previously assigned
Federal award identifier number. If a changed/corrected application, enter the
Federal Identifier in accordance with agency instructions.
Date Received by State: Leave this field blank. This date will be assigned by
the State, if applicable.

6.
7.

State Application Identifier: Leave this field blank. This identifier will be
assigned by the State, if applicable.

8.

Applicant Information: Enter the following in accordance with agency
instructions:
a. Legal Name: (Required): Enter the legal name of applicant that will
undertake the assistance activity. This is ththat the organization has
registered with the Central Contractor Registry. Information on registering with
CCR may be obtained by visiting the Grants.gov website.
b. Employer/Taxpayer Number (EIN/TIN): (Required): Enter the Employer
or Taxpayer Identification Number (EIN or TIN) as assigned by the Internal
Revenue Service. If your organization is not in the US, enter 44-4444444.

13.

14.

15.

16.

Areas Affected By Project: List the areas or entities using
the categories (e.g., cities, counties, states, etc.) specified in
agency instructions. Use the continuation sheet to enter
additional areas, if needed.
Descriptive Title of Applicant’s Project: (Required) Enter
a brief descriptive title of the project. If appropriate, attach a
map showing project location (e.g., construction or real
property projects). For preapplications, attach a summary
description of the project.
Congressional Districts Of: (Required) 16a. Enter the
applicant’s Congressional District, and 16b. Enter all
District(s) affected by the program or project. Enter in the
format: 2 characters State Abbreviation – 3 characters
District Number, e.g., CA-005 for California 5th district, CA012 for California 12th district, NC-103 for North Carolina’s
103rd district. • If all congressional districts in a state are
affected, enter “all” for the district number, e.g., MD-all for all
congressional districts in Maryland. • If nationwide, i.e. all
districts within all states are affected, enter US-all. • If the
program/project is outside the US, enter 00-000.

17.

Proposed Project Start and End Dates: (Required) Enter
the proposed start date and end date of the project.

18.

Estimated Funding: (Required) Enter the amount
requested or to be contributed during the first funding/budget
period by each contributor. Value of in-kind contributions
should be included on appropriate lines, as applicable. If the
action will result in a dollar change to an existing award,
indicate only the amount of the change. For decreases,
enclose the amounts in parentheses.

51

INSTRUCTIONS FOR THE SF-424A (continued)
narrative statement the nature and source of income. The
estimated amount of program income may be considered by the
Federal grantor agency in determining the total amount of the
grant.

Line 15 - Enter the totals of amounts on Lines 13 and 14.

Section C. Non-Federal Resources

Lines 16-19 - Enter in Column (a) the same grant program titles
shown in Column (a), Section A. A breakdown by function or
activity is not necessary. For new applications and continuation
grant applications, enter in the proper columns amounts of Federal
funds which will be needed to complete the program or project over
the succeeding funding periods (usually in years). This section
need not be completed for revisions (amendments, changes, or
supplements) to funds for the current year of existing grants.

Lines 8-11 Enter amounts of non-Federal resources that will be
used on the grant. If in-kind contributions are included, provide a
brief explanation on a separate sheet.
Column (a) - Enter the program titles identical to
Column (a), Section A. A breakdown by function or
activity is not necessary.
Column (b) - Enter the contribution to be made by the
applicant.
Column (c) - Enter the amount of the State’s cash and
in-kind contribution if the applicant is not a State or
State agency. Applicants which are a State or State
agencies should leave this column blank.
Column (d) - Enter the amount of cash and in-kind
contributions to be made from all other sources.
Column (e) - Enter totals of Columns (b), (c), and (d).

Line 12 - Enter the total for each of Columns (b)-(e). The amount
in Column (e) should be equal to the amount on Line 5, Column
(f), Section A.
Section D. Forecasted Cash Needs

Section E. Budget Estimates of Federal Funds Needed for
Balance of the Project

If more than four lines are needed to list the program titles, submit
additional schedules as necessary.
Line 20 - Enter the total for each of the Columns (b)-(e). When
additional schedules are prepared for this Section, annotate
accordingly and show the overall totals on this line.
Section F. Other Budget Information
Line 21 - Use this space to explain amounts for individual direct
object class cost categories that may appear to be out of the
ordinary or to explain the details as required by the Federal grantor
agency.
Line 22 - Enter the type of indirect rate (provisional, predetermined,
final or fixed) that will be in effect during the funding period, the
estimated amount of the base to which the rate is applied, and the
total indirect expense.
Line 23 - Provide any other explanations or comments deemed
necessary.

Line 13 - Enter the amount of cash needed by quarter from the
grantor agency during the first year.
Line 14 - Enter the amount of cash from all other sources needed
by quarter during the first year.

SF-424A (Rev. 7-97) Page 4

52

LOW INCOME TAXPAYER CLINIC

APPENDIX A
FEDERAL FINANCIAL REPORT
1. Federal Agency and Organizational Element
to Which Report is Submitted

(Follow form instructions)
2. Federal Grant or Other Identifying Number Assigned by Federal Agency
(To report multiple grants, use FFR Attachment)

Page

of
1

pages
3. Recipient Organization (Name and complete address including Zip code)

4a. DUNS Number

4b. EIN

8. Project/Grant Period
From: (Month, Day, Year)

5. Recipient Account Number or Identifying Number
(To report multiple grants, use FFR Attachment)

6. Report Type

7. Basis of Accounting

 Quarterly
 Semi-Annual
 Annual
 Final

 Cash  Accrual

9. Reporting Period End Date
(Month, Day, Year)

To: (Month, Day, Year)

10. Transactions

Cumulative

(Use lines a-c for single or multiple grant reporting)
Federal Cash (To report multiple grants, also use FFR Attachment):
a. Cash Receipts
b. Cash Disbursements
c. Cash on Hand (line a minus b)

(Use lines d-o for single grant reporting)
Federal Expenditures and Unobligated Balance:
d. Total Federal funds authorized
e. Federal share of expenditures
f. Federal share of unliquidated obligations
g. Total Federal share (sum of lines e and f)
h. Unobligated balance of Federal funds (line d minus g)
Recipient Share:
i. Total recipient share required
j. Recipient share of expenditures
k. Remaining recipient share to be provided (line i minus j)
Program Income:
l. Total Federal program income earned
m. Program income expended in accordance with the deduction alternative
n. Program income expended in accordance with the addition alternative
o. Unexpended program income (line l minus line m or line n)
a. Type
b. Rate
c. Period From Period To
11. Indirect
Expense

d. Base

e. Amount Charged

f. Federal Share

g. Totals:
12. Remarks: Attach any explanations deemed necessary or information required by Federal sponsoring agency in compliance with governing legislation:
13. Certification: By signing this report, I certify that it is true, complete, and accurate to the best of my knowledge. I am aware that
any false, fictitious, or fraudulent information may subject me to criminal, civil, or administrative penalities. (U.S. Code, Title 18, Section 1001)
a. Typed or Printed Name and Title of Authorized Certifying Official
c. Telephone (Area code, number and extension)
d. Email address
b. Signature of Authorized Certifying Official

e. Date Report Submitted (Month, Day, Year)

14. Agency use only:
Standard Form 425
OMB Approval Number: 0348-0061
Expiration Date: 10/31/2011

Paperwork Burden Statement
According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of information unless it displays a valid OMB Control Number. The valid OMB control
number for this information collection is 0348-0061. Public reporting burden for this collection of information is estimated to average 1.5 hours per response, including time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project ( 0348-0060), Washington, DC 20503.

53

APPENDIX A
Federal Financial Report Instructions
Report Submissions
1) Recipients will be instructed by Federal agencies to submit the Federal Financial Report (FFR) to
a single location, except when an automated payment management reporting system is utilized. In
this case, a second submission location may be required by the agency.
2)

If recipients need more space to support their FFRs, or FFR Attachments, they should provide
supplemental pages. These additional pages must indicate the following information at the top of
each page: Federal grant or other identifying number (if reporting on a single award), recipient
organization, Data Universal Numbering System (DUNS) number, Employer Identification Number
(EIN), and period covered by the report.

Reporting Requirements
1) The submission of interim FFRs will be on a quarterly, semi-annual, or annual basis, as directed by
the Federal agency. A final FFR shall be submitted at the completion of the award agreement. The
following reporting period end dates shall be used for interim reports: 3/31, 6/30, 9/30, or 12/31. For
final FFRs, the reporting period end date shall be the end date of the project or grant period.
2) Quarterly and semi-annual interim reports shall be submitted no later than 30 days after the end of
each reporting period. Annual reports shall be submitted no later than 90 days after the end of each
reporting period. Final reports shall be submitted no later than 90 days after the project or grant
period end date.
Note: For single award reporting:
1) Federal agencies may require both cash management information on lines 10(a) through 10(c) and
financial status information lines 10(d) through 10(o).
2) 10(b) and 10(e) may not be the same until the final report.

FFR
Number

Line Item Instructions for the Federal Financial Report

Reporting Item

Cover Information
1
Federal Agency and
Organizational Element to
Which Report is Submitted
2
Federal Grant or Other
Identifying Number
Assigned by Federal
Agency
3
Recipient Organization
4a
4b
5

54

Instructions

Enter the name of the Federal agency and organizational element
identified in the award document or as instructed by the agency.
For a single award, enter the grant number assigned to the award by the
Federal agency. For multiple awards, report this information on the FFR
Attachment. Do not complete this box if reporting on multiple awards.

Enter the name and complete address of the recipient organization
including zip code.
DUNS Number
Enter the recipient organization’s Data Universal Numbering System
(DUNS) number or Central Contract Registry extended DUNS number.
EIN
Enter the recipient organization’s Employer Identification Number (EIN).
Recipient Account Number Enter the account number or any other identifying number assigned by the
or Identifying Number
recipient to the award. This number is for the recipient’s use only and is
not required by the Federal agency. For multiple awards, report this

LOW INCOME TAXPAYER CLINIC

FFR
Number

6
7

8

9

Reporting Item

Instructions

information on the FFR Attachment. Do not complete this box if
reporting on multiple awards.
Report Type
Mark appropriate box. Do not complete this box if reporting on multiple
awards.
Basis of Accounting
Specify whether a cash or accrual basis was used for recording
(Cash/Accrual)
transactions related to the award(s) and for preparing this FFR. Accrual
basis of accounting refers to the accounting method in which expenses are
recorded when incurred. For cash basis accounting, expenses are recorded
when they are paid.
Project/Grant Period,
Indicate the period established in the award document during which
From: (Month, Day, Year) Federal sponsorship begins and ends.
Note: Some agencies award multi-year grants for a project period that is
funded in increments or budget periods (typically annual increments).
Throughout the project period, agencies often require cumulative
reporting for consecutive budget periods. Under these circumstances,
enter the beginning and ending dates of the project period not the budget
period.
Do not complete this line if reporting on multiple awards.
Project/Grant Period, To: See the above instructions for “Project/Grant Period, From: (Month, Day,
(Month, Day, Year)
Year).”
Reporting Period End
Enter the ending date of the reporting period. For quarterly, semi-annual,
Date: (Month, Day, Year) and annual interim reports, use the following reporting period end dates:
3/31, 6/30, 9/30, or 12/31. For final FFRs, the reporting period end date
shall be the end date of the project or grant period.

Transactions
Enter cumulative amounts from date of the inception of the award through the end date of the
reporting period specified in line 9.
Use Lines 10a through 10c, Lines 10d through 10o, or Lines 10a through 10o, as specified by the
Federal agency, when reporting on single grants.
Use Line 12, Remarks, to provide any information deemed necessary to support or explain FFR data.
Federal Cash (To report multiple grants, also use FFR Attachment)
10a
Cash Receipts
Enter the cumulative amount of actual cash received from the Federal
agency as of the reporting period end date.
10b
Cash Disbursements
Enter the cumulative amount of Federal fund disbursements (such as cash
or checks) as of the reporting period end date. Disbursements are the sum
of actual cash disbursements for direct charges for goods and services, the
amount of indirect expenses charged to the award, and the amount of cash
advances and payments made to subrecipients and contractors.
10

10c

Cash On Hand (Line 10a
Minus Line 10b

For multiple grants, report each grant separately on the FFR Attachment.
The sum of the cumulative cash disbursements on the FFR Attachment
must equal the amount entered on Line 10b, FFR.
Enter the amount of Line 10a minus Line 10b. This amount represents
immediate cash needs. If more than three business
days of cash are on hand, the Federal agency may require an explanation

55

FFR
Number

Reporting Item

Instructions

on Line 12, Remarks, explaining why the drawdown was made
prematurely or other reasons for the excess cash.
Federal Expenditures and Unobligated Balance: Do not complete this section if reporting on multiple
awards.
10d
Total Federal Funds
Enter the total Federal funds authorized as of the reporting period end
Authorized
date.
10e
Federal Share of
Enter the amount of Federal fund expenditures. For reports prepared on a
Expenditures
cash basis, expenditures are the sum of cash disbursements for direct
charges for property and services; the amount of indirect expense charged;
the value of third-party in-kind contributions applied; and the amount of
cash advance payments and payments made to subrecipients. For reports
prepared on an accrual basis, expenditures are the sum of cash
disbursements for direct charges for property and services; the amount of
indirect expense incurred; the value of in-kind contributions applied; and
the net increase or decrease in the amounts owed by the recipient for (1)
goods and other property received; (2) services performed by employees,
contractors, subrecipients, and other payees; and (3) programs for which
no current services or performance are required. Do not include program
income expended in accordance with the deduction alternative, rebates,
refunds, or other credits. (Program income expended in accordance with
the deduction alternative should be reported separately on Line 10o.)
10f
Federal Share of
Unliquidated obligations on a cash basis are obligations incurred, but not
Unliquidated Obligations yet paid. On an accrual basis, they are obligations incurred, but for which
an expenditure has not yet been recorded. Enter the Federal portion of
unliquidated obligations. Those obligations include direct and indirect
expenses incurred but not yet paid or charged to the award, including
amounts due to subrecipients and contractors. On the final report, this line
should be zero unless the awarding agency has provided other
instructions.
Do not include any amount in Line 10f that has been reported in Line 10e.
Do not include any amount in Line 10f for a future commitment of funds
(such as a long-term contract) for which an obligation or expense has not
been incurred.
10g
Total Federal Share (Sum Enter the sum of Lines 10e and 10f.
of Lines 10e and 10f)
10h
Unobligated Balance of
Enter the amount of Line 10d minus Line 10g.
Federal Funds (Line 10d
Minus Line 10g)
Recipient Share: Do not complete this section if reporting on multiple awards.
10i
Total Recipient Share
Enter the total required recipient share for reporting period specified in
Required
line 9. The required recipient share should include all matching and cost
sharing provided by recipients and third-party providers to meet the level
required by the Federal agency. This amount should not include cost
sharing and match amounts in excess of the amount required by the
Federal agency (for example, cost overruns for which the recipient incurs
additional expenses and, therefore, contributes a greater level of cost

56

LOW INCOME TAXPAYER CLINIC

APPENDIX A
FFR
Number

Reporting Item

Instructions

sharing or match than the level required by the Federal agency).
10j
Recipient Share of
Enter the recipient share of actual cash disbursements or outlays (less any
Expenditures
rebates, refunds, or other credits) including payments to subrecipients and
contractors. This amount may include the value of allowable third party
in-kind contributions and recipient share of program income used to
finance the non-Federal share of the project or program. Note: On the
final report this line should be equal to or greater than the amount of Line
10i.
10k
Remaining Recipient Share Enter the amount of Line 10i minus Line 10j. If recipient share in Line
to be Provided (Line 10i 10j is greater than the required match amount in Line 10i, enter zero.
Minus Line10j)
Program Income: Do not complete this section if reporting on multiple awards.
10l
Total Federal Program
Enter the amount of Federal program income earned. Do not report any
Income Earned
program income here that is being allocated as part of the recipient's cost
sharing amount included in Line10j.
10m
Program Income Expended Enter the amount of program income that was used to reduce the Federal
in Accordance With the
share of the total project costs.
Deduction Alternative
10n
Program Income Expended Enter the amount of program income that was added to funds committed
in Accordance With the
to the total project costs and expended to further eligible project or
Addition Alternative
program activities.
10o
Unexpended Program
Enter the amount of Line 10l minus Line 10m or Line 10n. This amount
Income (Line 10l Minus equals the program income that has been earned but not expended, as of
Line 10m or Line 10n)
the reporting period end date.
11
Indirect Expense: Complete this information only if required by the awarding agency and in
accordance with agency instructions.
11a
Type of Rate(s)
State whether indirect cost rate(s) is Provisional, Predetermined, Final, or
Fixed.
11b
Rate
Enter the indirect cost rate(s) in effect during the reporting period.
11c
Period From; Period To
Enter the beginning and ending effective dates for the rate(s).
11d
Base
Enter the amount of the base against which the rate(s) was applied.
11e
Amount Charged
Enter the amount of indirect costs charged during the time period
specified. (Multiply 11b. x 11d.)
11f
Federal Share
Enter the Federal share of the amount in 11e.
11g
Totals
Enter the totals for columns 11d, 11e, and 11f.
Remarks, Certification, and Agency Use Only
12
Remarks
Enter any explanations or additional information required by the Federal
sponsoring agency including excess cash as stated in line 10c.
13a
Typed or Printed Name and Enter the name and title of the authorized certifying official.
Title of Authorized
Certifying Official
13b
Signature of Authorized
The authorized certifying official must sign here.
Certifying Official
Enter the telephone number (including area code and extension) of the
13c
Telephone (Area Code,
Number and Extension)
individual listed in Line 13a.
13d
E-mail Address
Enter the e-mail address of the individual listed in Line 13a.

57

APPENDIX A
FFR
Number

13e
14

Reporting Item
Date Report Submitted
(Month, Day, Year)
Agency Use Only

Instructions
Enter the date the FFR is submitted to the Federal agency using the
month, day, year format.
This section is reserved for Federal agency use.

Line Item Instructions for the Federal Financial Report Attachment

(To be completed if reporting on cash management activity for multiple grants.)
Reporting Item
Instructions

Box
Number
1
Federal Agency and
Organizational Element to
Which Report is Submitted
2
Recipient Organization
3a
3b
4
5

58

Enter the name of the Federal agency and organizational element
identified in the award document or otherwise instructed by the agency.
(This information should be identical to that entered in Box 1, FFR.)
Enter the name and complete address of the recipient organization
including zip code. (Same information as entered in Box 3, FFR.)
DUNS Number
Enter the recipient organization’s Data Universal Numbering System
(DUNS) number or Central Contract Registry extended DUNS number.
(Same information as entered in Box 4a, FFR.)
EIN
Enter the recipient organization’s Employer Identification Number (EIN).
(Same information as entered in Box 4b, FFR.)
Reporting Period End Date: Enter the ending date of the reporting period of this report. (Same
(Month, Day, Year)
information as entered in Box 9, FFR.)
Federal Grant Number
Enter the grant number assigned to each award by the Federal agency.
Recipient Account Number Enter the account number or any other identifying number assigned by the
recipient to each award. This number is for the recipient’s use only and is
not required by the Federal agency.
Cumulative Federal Cash Enter the cumulative amount of the Federal share of cash disbursed for
Disbursement
each award. Cash disbursements are the sum of actual cash disbursements
for direct charges for goods and services, the amount of indirect expenses
charged to the award, and the amount of cash advances and payments
made to subrecipients and contractors.
Total
Enter the total for the Cumulative Cash Disbursement. This column
should equal the amount reported on Line 10b, FFR.

LOW INCOME TAXPAYER CLINIC

FEDERAL FINANCIAL REPORT ATTACHMENT
(For reporting multiple grants)

1. Federal Agency and Organizational Element
to Which Report is Submitted (Box 1 on Page 1)

3a. DUNS Number (Box 4a on Page 1)

2. Recipient Organization (Box 3 on Page 1)

4. Reporting Period End Date (Box 9 on Page 1)
(Month, Day, Year)

3b. EIN (Box 4b on Page 1)

Page __________ of _________

5. List Information below for each grant covered by this report. Use additional pages if more space is required.
Federal Grant Number

Recipient Account Number

Cumulative Federal Cash Disbursement

$

TOTAL (Should correspond to the amount on Line 10b on Page 1)

$

0.00
Standard Form 425A
OMB Approval Number: 0348-0061
Expiration Date: 10/31/2011

Paperwork Burden Statement
According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of information unless it displays a valid OMB Control Number. The valid
OMB control number for this information collection is 0348-0061. Public reporting burden for this collection of information is estimated to average thirty (30) minutes per response,
including time for reviewing instructions
instructions, searching existing data sources
sources, gathering and maintaining the data needed
needed, and completing and reviewing the collection of information
information.
Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management
and Budget, Paperwork Reduction Project ( 0348-0061), Washington, DC 20503.

59

In addition to the Instructions for SF-425, please pay close attention to the following lines:
Line 1

Internal Revenue Service

Line 2

Grant award number which can be found on the grant agreement (Form 12183)

Line 3

Sponsoring organization name and address

Line 5

Leave blank

Line 9

Interim Report- June 30 (and specify the year)
Year-End Report- Dec 31 (and specify the year)

Lines 10a through 10c

Leave blank

Line 10d

This is the amount of grant funds awarded for the entire grant cycle (Jan. 1 – Dec. 31)

Line 10e

This is the amount of grant funds already obligated for the reporting period

Line 10f

Leave blank

Line 10i

This is the total amount of matching funds for the entire grant cycle (and remember that you must have
matching funds in an amount equal to the amount of grant awarded)

Line 10j

This is amount of matching funds allocated for the reporting period

Lines 10l and10o

Leave blank

Line 11

Leave blank

60

LOW INCOME TAXPAYER CLINIC

APPENDIX A
ASSURANCES AND CERTIFICATIONS

Signing the certification on SF 424 certifies that the Applicant will comply with the Assurances and Certifications listed below if an award is made.
Certain of these Assurances and Certifications may not be applicable to the Applicant. An Applicant may not modify any of the Assurances and
Certifications.
A.
Standard Form 424B: Assurances -- Non-Construction Programs
As the duly authorized representative of the Applicant, I certify that the Applicant:
1.
Has the legal authority to apply for Federal assistance, and the institutional,
managerial and financial capability (including funds sufficient to pay the nonFederal share of project costs) to ensure proper planning, management and
completion of the project described in this Application.
2.
Will give the awarding agency, the Comptroller General of the United States, and if
appropriate, the State, through any authorized representative, access to and the
right to examine all records, books, papers, or documents related to the award; and
will establish a proper accounting system in accordance with generally accepted
accounting standards or agency directives.
3.
Will establish safeguards to prohibit employees from using their positions for a
purpose that constitutes or presents the appearance of personal or organizational
conflict of interest, or personal gain.
4.
Will initiate and complete the work (activities in Application) within the applicable
time frame after receipt of approval of the awarding agency.
5.
Will comply with the Intergovernmental Personnel Act of 1970 (42 U.S.C. 47284763) relating to prescribed standards for merit systems for programs funded
under one of the nineteen statutes or regulations specifies in Appendix A of OPM’s
Standards for a Merit System of Personnel Administration (5 CFR 900, Subpart F).
6.
Will comply with all Federal statutes relating to nondiscrimination. These include
but are not limited to: (a) Title VI of the Civil Rights Act of 1964 (P.L.88-352) which
prohibits discrimination on the basis of race, color or national origin; (b) Title IX of
the Education Amendments of 1972, as amended (20 U.S.C.1681-1683, 16851686), which prohibits discrimination on the basis of sex; (c) Section 504 of the
Rehabilitation Act of 1973, as amended (29 U.S.C.794), which prohibits
discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as
amended (42 U.S.C.6101-6107), which prohibits discrimination on the basis of
age; (e) the Drug Abuse Office and Treatment Act of 1972 (P.L. 92-255), as
amended, relating to nondiscrimination on the basis of drug abuse; (f) the
Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and
Rehabilitation Act of 1970 (P.L.91-616), as amended, relating to nondiscrimination
on the basis of alcohol abuse or alcoholism; (g) Sections 523 and 527 of the
Public Health Service Act of 1912 (42 U.S.C. 290 dd-3 and 290 ee-3), as
amended, relating to confidentiality of alcohol and drug abuse patient records; (h)
Title VIII of the Civil Rights Act of 1968 (42 U.S.C.3601 et seq.), as amended,
relating to nondiscrimination in the sale, rental or financing of housing; (i) any other
nondiscrimination provisions in the specific statute(s) under which Application for
Federal assistance is being made; and (j) the requirements of any other
nondiscrimination statutes which may apply to the Application.
7.
Will comply, or has already complied, with the requirements of Titles II and III of the
Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970
(P.L. 91-646) which provide for fair and equitable treatment of persons displaced or
whose property is acquired as a result of Federal or federally assisted programs.
These requirements apply to all interests in real property acquired for project
purposes regardless of Federal participation in purchases.
8.
Will comply with the provisions of the Hatch Act (5 U.S.C.1501-1508 & 7324-7328)
which limit the political activities of employees whose principal employment
activities are funded in whole or in part with Federal funds.
9.
Will comply, as applicable, with the provisions of the Davis-Bacon Act (40 U.S.C.
276a to 276a-7), the Copeland Act (40 U.S.C. 276c and 18 U.S.C. 874), and the
Contract Work Hours and Safety Standards Act (40 U.S.C. 327-333), regarding
labor standards for federally assisted construction subagreements.
10. Will comply, if applicable, with flood insurance purchase requirements of Section
102(a) of the Flood Disaster Protection Act of 1973 (P.L. 93-234) which requires
recipients in a special flood hazard area to participate in the program and to
purchase flood insurance if the total cost of insurable construction and acquisition
is $10,000 or more.
11. Will comply with environmental standards which may be prescribed pursuant to the
following: (a) institution of environmental quality control measures under the
National Environmental Policy Act of 1969 (P.L.91-190) and Executive Order
11514; (b) notification of violating facilities pursuant to EO 11738; (c) protection of
wetlands pursuant to EO 11990; (d) evaluation of flood hazards in floodplains in
accordance with EO 11988; (e) assurance of project consistency with the approved
State management program developed under the Coastal Zone Management Act
of 1972 (16 U.S.C. 1451et seq.); (f) conformity of Federal actions to State
Implementation Plans under Section 176(c) of the Clear Air Act of 1955, as

CDFI Fund, Form CDFI-0020

- 72 -

12.
13.

14.
15.

16.
17.
18.

amended (42 U.S.C. 7401 et seq.); (g) protection of underground sources of
drinking water under the Safe Drinking Water Act of 1974, as amended, (P.L.93523); and (h) protection of endangered species under the Endangered Species Act
of 1973, as amended, (P.L.93-205).
Will comply with the Wild and Scenic Rivers Act of 1968 (16 U.S.C. 1271 et seq.)
related to protecting components or potential components of the national wild and
scenic rivers system.
Will assist the awarding agency in assuring compliance with Section 106 of the
National Historic Preservation Act of 1966, as amended (16 U.S.C. 470), EO
11593 (identification and protection of historic properties), and the Archaeological
and Historic Preservation Act of 1974 (16 U.S.C. 469a-1 et seq.).
Will comply with P.L. 93-348 regarding the protection of human subjects involved in
research, development, and related activities supported by this award of
assistance.
Will comply with the Laboratory Animal Welfare Act of 1966 (P.L. 89-544, as
amended, 7 U.S.C. 2131 et seq.) pertaining to the care, handling, and treatment of
warm blooded animals held for research, teaching, or other activities supported by
this award of assistance.
Will comply with the Lead-Based Paint Poisoning Prevention Act (42 U.S.C. 4801
et seq.) which prohibits the use of lead based paint in construction or rehabilitation
of residence structures.
Will cause to be performed the required financial and compliance audits in
accordance with the Single Audit Act of 1984.
Will comply with all applicable requirements of all other Federal laws, executive
orders, regulations and policies governing this program.

B. Additional Certifications
In addition to the assurances and certifications provided by the Applicant pursuant to
OMB Standard Form 424B, the Applicant hereby assures and certifies that:
1.
It is duly organized and validly existing under the laws of the jurisdiction in which it
was incorporated or otherwise established, and is (or within 30 days will be)
authorized to do business in any jurisdiction in which it proposes to undertake
activities specified in this Application;
2.

3.

4.

5.

6.

C.
1.
2.

Its Board of Directors (or similar governing body) has by proper resolution or
similar action authorized the filing of this Application, including all understandings
and assurances contained herein, and directed and authorized the person
identified as the authorized representative of the Applicant to act in connection with
this Application and to provide such additional information as may be required;
It will comply with all applicable requirements of the Community Development
Banking and Financial Institutions Act of 1994 (the Act) [12 U.S.C. 4701 et seq.],
regulations implementing the Act and all other applicable Department of the
Treasury regulations and implementing procedures (and any regulations or
procedures which are later promulgated to supplement or replace them);
It will comply, as applicable and appropriate, with the requirements of OMB
Circulars (e.g., A-110 and A-133) and any regulations and circulars which are later
promulgated to supplement or replace them, including standards for fund control
and accountability;
It has not knowingly and willfully made or used a document or writing containing
any false, fictitious or fraudulent statement or entry as part of this Application or
any related document, correspondence or communication. (The Applicant and its
authorized representative should be aware that, under 18 U.S.C. 1001, whoever
knowingly and willfully makes or uses such document or writing shall be fined or
imprisoned for not more than five years, or both); and
The information in this Application, and in these assurances and certifications in
support of the Application, is true and correct to the best of the Applicant’s
knowledge and belief and the filing of this Application has been duly authorized.
Certification Regarding Debarment, Suspension, and Other Responsibility
Matters -- Primary Covered Transactions: Instructions for Certification
By signing and submitting this Application, the prospective primary participant (the
Applicant) is providing the certification set out below.
The inability of a person to provide the certification required below will not
necessarily result in the denial of participation in this covered transaction. The
prospective Applicant shall submit an explanation of why it cannot provide the
certification set out below. The certification or explanation will be considered in
connection with the Fund’s determination whether to enter into this transaction
(approval and funding of the Application). However, failure of the Applicant to

FY 2008 CDFI Program Application

61

APPENDIX A

3.

4.
5.

6.

7.

8.

9.

10.

D.
1.

2.
E.
1.

furnish a certification or an explanation shall disqualify such person from
(b) establishing a drug-free awareness program to inform employees about:
participation in this transaction.
(i) the dangers of drug abuse in the workplace;
This certification is a material representation of fact upon which reliance is placed
(ii) the Applicant’s policy of maintaining a drug-free workplace;
when the Fund determines to enter into this transaction. If it is later determined
(iii) any available drug counseling, rehabilitation, and employee assistance
that the Applicant knowingly rendered an erroneous certification, in addition to
program;
other remedies available to the Federal Government, the Fund may terminate this
(iv) the penalties that may be imposed upon employees for drug abuse
transaction for cause or default.
violations occurring in the workplace
The Applicant shall provide immediate written notice to the Fund if at any time the
(c) making it a requirement that each employee to be engaged in the
Applicant learns that its certification was erroneous when submitted or has become
performance of the award be given a copy of the statement required by
erroneous by reason of changed circumstances.
subparagraph (a);
The terms “covered transactions,” “debarred,” “suspended,” “ineligible,” “lower tier
(d) notifying the employee in the statement required by subparagraph (a) that,
covered transaction,” “participant,” “person,” “primary covered transaction,”
as a condition of employment in such grant, the employee will:
“principal,” “proposal”, and “voluntarily excluded,” as used in this clause
(i) abide by the terms of the statement; and
(certification), have the meanings set out in the Definitions and Coverage sections
(ii) notify the employer of any criminal drug use statute conviction for a
of the rules implementing Executive Order 12549. You may contact the Fund for
violation occurring in the workplace no later than five calendar days
assistance in obtaining a copy of those regulations (31 CFR part 19).
after such conviction;
The Applicant agrees by submitting this Application that, should the proposed
(e)
notifying
the granting agency in writing, within ten calendar days after
covered transaction be entered into, it shall not knowingly enter into any lower tier
receiving notice of a conviction under subparagraph (d) (ii) from an
covered transaction with a person who is debarred, suspended, declared ineligible,
employee or otherwise receiving actual notice of such conviction;
or voluntarily excluded from participation in this covered transaction, unless
(f) taking one of the following actions, within 30 days of receiving notice under
authorized by the Fund.
subparagraph (d)(ii), with respect to any employee who is so convicted:
The Applicant further agrees by submitting this Application that it will include the
(i) taking appropriate personnel action against such an employee, up to
clause titled “Certification Regarding Debarment, Suspension, Ineligibility and
and including termination, consistent with the requirements of the
Voluntary Exclusion-Lower Tier Covered Transaction,” to be provided by the Fund,
Rehabilitation Act of 1973, as amended; or
without modification, in all lower tier covered transactions and in all solicitations for
(ii) requiring such employee to participate satisfactorily in a drug abuse
lower tier covered transactions (see 31 CFR part 19, Appendix B).
assistance or rehabilitation program approved for such purposes by a
A participant in a covered transaction may rely upon a certification of a prospective
Federal, State, or local health, law enforcement, or other appropriate
participant in a lower tier covered transaction that it is not debarred, suspended,
agency; and
ineligible, or voluntarily excluded from the covered transaction, unless it knows that
(g) making a good faith effort to continue to maintain a drug-free workplace
the certification is erroneous. A participant may decide the method and frequency
through implementation of subparagraphs (a), (b), (c), (d), (e), and (f).
by which it determines the eligibility of its principals. Each participant may, but is
2.
The Applicant may insert in the space provided below the site(s) for the
not required to, check the Nonprocurement List.
performance of work (activities carried out by the Applicant) to be done in
Nothing contained in the foregoing shall be construed to require establishment of a
connection with the award (Place of Performance (Street Address, City, County,
system of records in order to render in good faith the certification required by this
State and zip Code)):
clause. The knowledge and information of a participant is not required to exceed
Not Applicable
that which is normally possessed by a prudent person in the ordinary course of
business dealings.
F. Certification Regarding Lobbying
Except for transactions authorized under paragraph 6 of these instructions, if a
1.
The Applicant certifies, to the best of its knowledge and belief, that:
participant in a covered transaction knowingly enters into a lower tier covered
transaction with a person who is suspended, debarred, ineligible, or voluntarily
(a) No Federal appropriated funds have been paid or will be paid, by or on
excluded from participation in this transaction, in addition to other remedies
behalf of the Applicant, to any person for influencing or attempting to
available to the Federal Government, the Fund may terminate this transaction for
influence an officer or employee of any agency, a Member of Congress, an
cause or default.
officer or employee of Congress, or an employee of a Member of Congress
in connection with the awarding of any Federal contract, the making of any
Certification Regarding Debarment, Suspension, and Other Responsibility
Federal grant, the making of any Federal loan, the entering into of any
Matters -- Primary Covered Transactions
cooperative agreement, and the extension, continuation, renewal,
The prospective primary participant (the Applicant) certifies to the best of its
amendment, or modification of any Federal contract, grant, loan, or
knowledge and belief, that it and its principals:
cooperative agreement;
(a) are not presently debarred, suspended, proposed for debarment, declared
(b) If any funds other than Federal appropriated funds have been paid or will be
ineligible, or voluntarily excluded from covered transactions by any Federal
paid to any person for influencing or attempting to influence an officer or
department or agency;
employee of any agency, a Member of Congress, an officer or employee of
(b) have not within a three-year period preceding this Application been
Congress, or an employee of a Member of Congress in connection with this
convicted of or had a civil judgment rendered against them for commission of
Application, the undersigned shall complete and submit Standard Form LLL,
fraud or a criminal offense in connection with obtaining, attempting to obtain,
“Disclosure Form to Report Lobbying, “ in accordance with its instructions;
or performing a public (Federal, State or local) transaction or contract under
and
a public transaction; violation of Federal or State antitrust statutes or
(c) The Applicant shall require that the language of this certification be included
commission of embezzlement, theft, forgery, bribery, falsification or
in the award documents for all subawards of all tiers (including subcontracts,
destruction of records, making false statements, or receiving stolen property;
subgrants, and contracts under grants, loans, and cooperative agreements)
(c) are not presently indicted for or otherwise criminally or civilly charged by a
and that all subrecipients shall certify and disclose accordingly.
governmental entity (Federal, State or local) with commission of any of the
2. This certification is a material representation of fact upon which reliance is placed
offenses enumerated in paragraph (1)(b) of this certification; and
when this transaction is made or entered into. Submission of this certification is a
(d) Have not within a three-year period preceding this Application had one or
prerequisite for making or entering into this transaction imposed by section 1352,
more public transactions (Federal, State or local) terminated for cause or
title 31, U.S. Code. Any person who fails to file the required certification shall be
default.
subject to a civil penalty of not less than $10,000 and not more than $100,000 for
Where the Applicant is unable to certify to any of the statements in this certification,
each such failure.
such Applicant shall attach an explanation to this proposal.
Certification Regarding Drug-Free Workplace Requirements
The Applicant certifies that it will provide a drug-free workplace by:

(a)

publishing a statement notifying employees that the unlawful manufacture,
distribution, dispensing, possession, or use of a controlled substance is
prohibited in the Applicant’s workplace and specifying the actions that will be
taken against employee for violations of such prohibition;

CDFI Fund,
Form CDFI-0020
LOW INCOME
TAXPAYER CLINIC
62

- 73 -

FY 2008 CDFI Program Application

DISCLOSURE OF LOBBYING ACTIVITIES

Approved by OMB

Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352
0348-0046
(See reverse for public burden disclosure.)
1. Type of Federal Action:
2. Status of Federal Action:
3. Report Type:
a. contract
a. bid/offer/application
a. initial filing
b. grant
b. initial award
b. material change
c. cooperative agreement
c. post-award
For Material Change Only:
d. loan
year _________ quarter _________
e. loan guarantee
date of last report ______________
f. loan insurance
4. Name and Address of Reporting Entity:
5. If Reporting Entity in No. 4 is a Subawardee, Enter Name
Subawardee
and Address of Prime:
Prime
Tier ______, if known :

Congressional District, if known : 4c
6. Federal Department/Agency:

Congressional District, if known :
7. Federal Program Name/Description:
CFDA Number, if applicable : _____________

8. Federal Action Number, if known :

9. Award Amount, if known :
$

10. a. Name and Address of Lobbying Registrant
( if individual, last name, first name, MI ):

b. Individuals Performing Services (including address if
different from No. 10a )
( last name, first name, MI ):

requested through this form is authorized by title 31 U.S.C. section
11. Information
1352. This disclosure of lobbying activities is a material representation of fact

Signature:

upon which reliance was placed by the tier above when this transaction was made
or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This
information will be available for public inspection. Any person who fails to file the
required disclosure shall be subject to a civil penalty of not less than $10,000 and
not more than $100,000 for each such failure.

Federal Use Only:

Print Name:
Title:
Telephone No.: _______________________ Date:
Authorized for Local Reproduction
Standard Form LLL (Rev. 7-97)

63

DISCLOSURE OF LOBBYING ACTIVITIES

Approved by OMB

Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352
0348-0046
(See reverse for public burden disclosure.)
1. Type of Federal Action:
2. Status of Federal Action:
3. Report Type:
a. contract
a. bid/offer/application
a. initial filing
b. grant
b. initial award
b. material change
c. cooperative agreement
c. post-award
For Material Change Only:
d. loan
year _________ quarter _________
e. loan guarantee
date of last report ______________
f. loan insurance
4. Name and Address of Reporting Entity:
5. If Reporting Entity in No. 4 is a Subawardee, Enter Name
Subawardee
and Address of Prime:
Prime
Tier ______, if known :

Congressional District, if known : 4c
6. Federal Department/Agency:

Congressional District, if known :
7. Federal Program Name/Description:
CFDA Number, if applicable : _____________

8. Federal Action Number, if known :

9. Award Amount, if known :
$

10. a. Name and Address of Lobbying Registrant
( if individual, last name, first name, MI ):

b. Individuals Performing Services (including address if
different from No. 10a )
( last name, first name, MI ):

requested through this form is authorized by title 31 U.S.C. section
11. Information
1352. This disclosure of lobbying activities is a material representation of fact

Signature:

upon which reliance was placed by the tier above when this transaction was made
or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This
information will be available for public inspection. Any person who fails to file the
required disclosure shall be subject to a civil penalty of not less than $10,000 and
not more than $100,000 for each such failure.

Federal Use Only:

64

LOW INCOME TAXPAYER CLINIC

Print Name:
Title:
Telephone No.: _______________________ Date:
Authorized for Local Reproduction
Standard Form LLL (Rev. 7-97)

APPENDIX A
INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES
This disclosure form shall be completed by the reporting entity, whether subawardee or prime Federal recipient, at the initiation or receipt of a covered Federal
action, or a material change to a previous filing, pursuant to title 31 U.S.C. section 1352. The filing of a form is required for each payment or agreement to make
payment to any lobbying entity for influencing or attempting to influence an officer or employeeof any agency, a Member of Congress, an officer or employee of
Congress, or an employeeof a Member of Congress in connection with a covered Federal action. Complete all items that apply for both the initial filing and material
change report. Refer to the implementing guidance published by the Office of Management and Budget for additional information.

1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action.
2. Identify the status of the covered Federal action.
3. Identify the appropriate classification of this report. If this is a followup report caused by a material change to the information previously reported, enter
the year and quarter in which the change occurred. Enter the date of the last previously submitted report by this reporting entity for this covered Federal
action.
4. Enter the full name, address, city, State and zip code of the reporting entity. Include Congressional District, if known. Check the appropriateclassification
of the reporting entity that designates if it is, or expects to be, a prime or subaward recipient. Identify the tier of the subawardee,e.g., the first subawardee
of the prime is the 1st tier. Subawards include but are not limited to subcontracts, subgrants and contract awards under grants.
5. If the organization filing the report in item 4 checks "Subawardee," then enter the full name, address, city, State and zip code of the prime Federal
recipient. Include Congressional District, if known.
6. Enter the name of the Federal agency making the award or loan commitment. Include at least one organizationallevel below agency name, if known. For
example, Department of Transportation, United States Coast Guard.
7. Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the full Catalog of Federal Domestic Assistance
(CFDA) number for grants, cooperative agreements, loans, and loan commitments.
8. Enter the most appropriate Federal identifying number available for the Federal action identified in item 1 (e.g., Request for Proposal (RFP) number;
Invitation for Bid (IFB) number; grant announcement number; the contract, grant, or loan award number; the application/proposal control number
assigned by the Federal agency). Include prefixes, e.g., "RFP-DE-90-001."
9. For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal amount of the award/loan
commitment for the prime entity identified in item 4 or 5.
10. (a) Enter the full name, address, city, State and zip code of the lobbying registrant under the Lobbying Disclosure Act of 1995 engaged by the reporting
entity identified in item 4 to influence the covered Federal action.
(b) Enter the full names of the individual(s) performing services, and include full address if different from 10 (a). Enter Last Name, First Name, and
Middle Initial (MI).
11. The certifying official shall sign and date the form, print his/her name, title, and telephone number.
According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of information unless it displays a valid OMB Control
Number. The valid OMB control number for this information collection is OMB No. 0348-0046. Public reporting burden for this collection of information is
estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0046), Washington,
DC 20503.

65

APPENDIX A
Low Income Taxpayer Clinics (LITCs)
Application Information
Type of Grant (Check one)

ESL

Controversy

or

Both

Grant year: _________

Grant Period Request (Check one)
New or Single Year request
Multi-year request (currently in or applying for a multi-year grant)

1st of 3 years

2nd of 3 years

3rd of 3 years

Sponsoring Organization Information
Name
Contact Information
Name

Title

Phone number

Fax number

E-mail address

Street Address
Street

Mailing Address
Street

City

State

Clinic Information

ZIP + 4 code

City

State

ZIP + 4 code

Information from this section will be included in Publication 4134, Low Income Taxpayer Clinic List.

Name of Clinic
Clinic Street Address
Street
City

Clinic Mailing Address
Street
State

ZIP + 4 code

City

State

Public telephone number

Toll-Free telephone number (if applicable)

Languages served in addition to English

LITC Internet (Web) address (if applicable)

Clinic Director Information
Name

Title

Phone number

Fax number

ZIP + 4 code

E-mail address

Grants Officer/Financial Administrator Information (Funds will be forwarded to this address)
Name

Title

Phone number

Fax number

E-mail address

Street Address
Street

Mailing Address
Street

City

State

Form 13424 (Rev. 5-2009)

Catalog Number 36126D

2010

66

LOW INCOME TAXPAYER CLINIC

ZIP + 4 code

City

www.irs.gov

State

ZIP + 4 code

Department of the Treasury-Internal Revenue Service

LITC Tax Information Authorization
As provided for in Publication 3319, all applicants for an LITC grant must be in
compliance with Federal tax responsibilities. The LITC Program Office will conduct
compliance checks on organizations applying for an LITC grant and will also conduct
periodic checks throughout the grant period. Therefore, any LITC that is part of a larger
organization (e.g., university) will need to have an authorized official from the larger
organization complete the following authorization:
Name of Academic Institution or other Parent Organization:
Name of Low Income Taxpayer Clinic:

I authorize the Internal Revenue Service to disclose the following return information, as
that term is defined in Internal Revenue Code section 6103(b), of the Academic
Institution or Parent Organization (listed above) to the Director of the Low Income
Taxpayer Clinic (listed above) in connection with the clinic’s application for a low income
taxpayer clinic matching grant and continued entitlement to such grant. Specifically, I
authorize the Internal Revenue Service to disclose that the Academic Institution or
Parent Organization has an outstanding federal tax liability (amount, type of tax, and
periods) that may affect the approval of the clinic’s grant application by the Internal
Revenue Service or the clinic’s continued entitlement to such grant.
I am aware that without this authorization the return information of the Academic
Institution or Parent Organization is confidential and is protected by law under the
Internal Revenue Code. I certify that I am authorized by law to bind the Academic
Institution or Parent Organization and that I have authority to execute this consent to
disclose return information.
Taxpayer Name: _____________________________
Taxpayer Address: ______________________________
______________________________
Employer Identification Number: ____________________
Name and Title of Authorized Person: ___________________________
Signature of Authorized Person: ________________________________
Telephone Number of Authorized Person: _________________________
Date: ____________________

67

APPENDIX A
GRANT AGREEMENT
The Grant Agreement is entered into by the Internal Revenue Service, Department of the Treasury, United States of
America, hereinafter referred to as the IRS, and ______________________________________________________
Contract Number __________________, hereinafter referred to as the recipient.
The recipient agrees to operate an LITC Program in conformity with the approved Grant Application, which is
governed by:
1.

26 U.S.C. § 7526; and

2.

LITC Program Requirements (as stated in Publicati on 3319, "Low Income Taxpayer Clinics 2008 Grant
Application Package and Guidelines");

Grant Agreement Period:
NOTE: If expenses are incurred prior to approval, and the grant is later denied, all costs incurred will be the
responsibility of the Recipient.
Maximum Amount of Funds Available from the IRS for Expense Reimbursement:
The Maximum amount available from the IRS under this Grant Agreement is $___________ . This amount may be
increased in writing only by the IRS, Taxpayer Advocate Service, LITC Program Office, TA:LITC,
1111 Constitution Ave., NW, Room 1034, Washington, DC 20224.
Implementation of the Trafficking Victims Protection Act of 2000, as amended (22 U.S.C. § 7104) – See 2
C.F.R. § 175.15 (2007)
1. You as the recipient, your employees, subrecipients under this award, and subrecipients’ employees may not—
i.) Engage in severe forms of trafficking in persons during the period of time that the award is in effect;
ii.) Procure a commercial sex act during the period of tim e that the award is in effect; or
iii.) Use forced labor in the performance of the award or subawards under the award.
2. The IRS, as the Federal awarding agency may unilaterally terminate this award, without penalty, if you or a
subrecipient that is a private entityi) Is determined to have violated a prohibition in paragraphs (1)(i) – (iii) above of this award term; or
ii.) Has an employee who is determined by the IRS official authorized to terminate the award to have
violated a prohibition in paragraphs (1)(i)-(iii) of this award term through conduct that is either –
A. Associated with performance under this award; or
B. Imputed to you or the subrecipient using the standards and due process for imputing the conduct
of an individual to an organization that are provided in 2 CFR part 180, “OMB Guidelines to
Agencies on Governmentwide Debarment and Suspension (Nonprocurement),” as implemented by
the IRS in Publication 3319.
Approved by an Authorized Representative of the Program Sponsor by:
Name (Please Print)
Title
Signature

Date

Approved for the IRS by:
Name (Please Print)

Title

Signature

Date

Form 12183 (Rev. 2/2008) Catalog No. 26967 www.irs.gov Department of the Treasury Internal Revenue Service

68

LOW INCOME TAXPAYER CLINIC

APPENDIX B

LITC Program Grant Application Checklists
and LITC Program Report Package Submission

69

This page intentionally left blank.

70

LOW INCOME TAXPAYER CLINIC

APPENDIX B
LITC PROGRAM GRANT APPLICATION PACKAGE SUBMISSION CHECKLIST
NEW OR SINGLE YEAR GRANT APPLICATIONS

an

New or single year applications for the LITC Program Grant Application must include the following information:
Background Information (limited to 15 pages, double spaced)
Items described under Section VI of this package.
Determination of Program Performance
Items described under Section VI of this package.
Budget/Financial Information
Items described under Section VI of this package.
Requisites for Package Submission
Submit application in quadruplicate (four sets). Double space and sign all documents (application, certifications,
etc) in blue ink. Each set must have original signatures.
Package Assembly
It is very important that the LITC Program Grant Application Package be assembled correctly. A copy of the
standard forms and certifications are included Appendix A of this publication. The application package must be
assembled in the following manner:
in
__ 1. 2 Standard Form 424, Application for Federal Assistance.
__ 2. 3 Background Information.
__ 3. 4 Copy of determination letter issued by IRS recognizing organization as exempt under IRC Section 501(c) (if
applicable).
__ 4. 5 Copy of letter of academic accreditation for college, university or other institution of higher learning (if
applicable).
__ 5. 6 Determination of Program Performance (one for each qualifying program, if applicable).
__ 6. 7 Budget/Financial Information (one for each qualifying program, if applicable).
__ 7. 1 Completed Form 13424, IRS Low Income Taxpayer Clinic (LITC) Program Grant Application Sheet.
__ 8. 9 Standard Form LLL, Disclosure of Lobbying Activities, signed in blue ink by an authorized representative
of the organization.
__ 9. 10Tax Information Authorization (if applicable) signed in blue ink by an authorized representative of the
organization.
8. Civil Rights Statement as described in Section IV, D of this package.

71

APPENDIX B
LITC PROGRAM GRANT APPLICATION PACKAGE SUBMISSION CHECKLIST
CONTINUING MULTI-YEAR GRANT APPLICATIONS
an

Continuing multi-year applications for the LITC Program Grant Application must include the following information:
Continuation Request
Letter described under Section VI of this package.
Budget/Financial Information
Items described under section VI of this package.
Requisites for Package Submission
Submit application in quadruplicate (four sets). Double Space and sign all documents (application, certifications,
etc) in blue ink. Each set must have original signatures.
Each set must have original signatures.
Package Assembly
It is very important that the LITC Program Grant Application Package be assembled correctly. A copy of the
standard forms and certifications are included Appendix A of this publication. The application package must be
assembled in the following manner:
in
__ 1. 2 Standard Form 424, Application for Federal Assistance.

2011

__ 2. 3 Letter requesting continuation in the LITC Program for the 2010 grant cycle.
__ 3. 4 Standard Form 424A, Budget Information – Non-Construction Programs (one for each qualifying
program (controversy and ESL), if applicable).
__ 4. 5 Budget Narrative (one for each qualifying program (controversy and ESL), if applicable).
__ 5. 6 Detailed description of matching funds. the source of

2010

__ 6. 7 Estimate of funds that will not be expended during the 2009 year.

__ 7. 1 Completed Form 13424, IRS Low Income Taxpayer Clinic (LITC) Program Grant Application Sheet.
__ 8.

Civil Rights Statement as described in Section IV, D.

__ 9.

Standard Form LLL, Disclosure of Lobbying Activities, signed in blue ink by an authorized representative
of the organization.

of this package

__ 10. Tax Information Authorization (if applicable) signed in blue ink by an authorized representative of the
organization.

72

LOW INCOME TAXPAYER CLINIC

LITC Program Interim Report Package Submission Checklist

A completed Form 425, Federal Financial Report and Form 425a, Federal Financial Report Attachment (if necessary)
for the period January 1 through June 30.
A complete financial narrative, describing how grant funds were expended for the period January 1 through June 30.
If you are funded for both controversy and ESL each needs a separate financial narrative.
Statement of unused funds
If Applicable – Additional Funding Request. If your organization would like to request
additional funding, include a separate letter requesting additional funding and explain how the
funds will be spent. The grant award and amount of additional funds being requested cannot
exceed $100,000.
Program Narrative must include the following:
Detailed strategy used for monitoring/evaluating program
Description of how program success is defined and measured
Explanation of the progress made in implementing the program
Status of proposed goals and objectives
Description of impediments to meeting established goals and objectives
Description of the clinic’s efforts to publicize the program
Description of the type of representation or other assistance and name of workshops
Description of any additional activities not described previously
Description of any Interesting Issue or Success Story (be careful not to include taxpayer
identifying information)
Statement describing the reason a controversy case was accepted where the amount in
controversy exceeded $50,000

Supplemental Issues Form (Form 13424-B in Appendix C (controversy only))
Interim and Year-End Report Form (Form 13424-A in Appendix C)
Advocacy Report Form (Form 13424-C in Appendix C)

73

LITC Program Annual Report Package Submission Checklist

A completed Form 425, Federal Financial Report and Form 425a, Federal Financial Report Attachment (if necessary)
for the period January 1 through December 31.
A complete financial narrative, describing how grant funds were expended for the period January 1 through
December 31.
Itemization and explanation of the actual costs for all expenses.
The source, date, availability and amount of matching funds received for the LITC program.
Separate financial narratives for ESL and Controversy.
Statement of amount of unobligated funds.
Program Narrative for the period January 1 through December 31
Implementation of the LITC Program
Information provided to ESL taxpayers
Training provided to students, volunteers, and LITC employees
Case tracking
Publicity for the LITC
Referral Mechanism for Controversies
Privacy and confidentiality
Pro Bono panel
Nominal fees (if any)
Delivery of services
Miscellaneous
Program goals
Additional Activities (include Interesting Issues or Success Stories but be careful not to include
taxpayer identifying information)
Last Year in LITC Program (if applicable)
Special orders for student practice
Statement describing the reason a controversy case was accepted where the amount in
controversy exceeded $50,000

Supplemental Issues Form (Form 13424-B in Appendix C (controversy only))
Interim and Year-End Report Form (Form 13424-A in Appendix C)
Advocacy Report Form (Form 13424-C in Appendix C)

74

LOW INCOME TAXPAYER CLINIC

APPENDIX C

Interim and Year-End Report Form and Instructions
and Supplemental Issues Formand Instructions

75

APPENDIX C
INSTRUCTIONS FOR THE SF-424
Public reporting burden for this collection of information is estimated to average 60 minutes per response, including time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the
Office of Management and Budget, Paperwork Reduction Project (0348-0043), Washington, DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET. SEND IT TO THE ADDRESS
PROVIDED BY THE SPONSORING AGENCY.

This is a standard form (including the continuation sheet) required for use as a cover sheet for submission of preapplications and applications and
related information under discretionary programs. Some of the items are required and some are optional at the discretion of the applicant or the
Federal agency (agency). Required items are identified with an asterisk on the form and are specified in the instructions below. In addition to the
instructions provided below, applicants must consult agency instructions to determine specific requirements.
Item
1.

2.

Entry:
Type of Submission: (Required): Select one type of submission in
accordance with agency instructions.
• Preapplication
• Application
• Changed/Corrected Application – If requested by the agency, check if this
submission is to change or correct a previously submitted application. Unless
requested by the agency, applicants may not use this to submit changes after
the closing date.

Item
10.

Entry:
Name Of Federal Agency: (Required) Enter the name of
the Federal agency from which assistance is being
requested with this application.

11.

Type of Application: (Required) Select one type of application in accordance
with agency instructions.

12.

Catalog Of Federal Domestic Assistance Number/Title:
Enter the Catalog of Federal Domestic Assistance number
and title of the program under which assistance is
requested, as found in the program announcement, if
applicable.
Funding Opportunity Number/Title: (Required) Enter the
Funding Opportunity Number and title of the opportunity
under which assistance is requested, as found in the
program announcement.
Competition Identification Number/Title: Enter the
Competition Identification Number and title of the
competition under which assistance is requested, if
applicable.

• New – An application that is being submitted to an agency for the first time.
• Continuation - An extension for an additional funding/budget period for a
project with a projected completion date. This can include renewals.
• Revision - Any change in the Federal Government’s financial obligation or
contingent liability from an existing obligation. If a
revision, enter the appropriate letter(s). More than one may be
selected. If "Other" is selected, please specify in text box provided.
A. Increase Award
B. Decrease Award
C. Increase Duration
D. Decrease Duration
E. Other (specify)

3.

Date Received: Leave this field blank. This date will be assigned by the
Federal agency.

4.

Applicant Identifier: Enter the entity identifier assigned buy the Federal
agency, if any, or the applicant’s control number if applicable.

5a.

Federal Entity Identifier: Enter the number assigned to your
organization by the Federal Agency, if any.

5b.

Federal Award Identifier: For new applications leave blank. For a
continuation or revision to an existing award, enter the previously assigned
Federal award identifier number. If a changed/corrected application, enter the
Federal Identifier in accordance with agency instructions.
Date Received by State: Leave this field blank. This date will be assigned by
the State, if applicable.

6.
7.

State Application Identifier: Leave this field blank. This identifier will be
assigned by the State, if applicable.

8.

Applicant Information: Enter the following in accordance with agency
instructions:
a. Legal Name: (Required): Enter the legal name of applicant that will
undertake the assistance activity. This is ththat the organization has
registered with the Central Contractor Registry. Information on registering with
CCR may be obtained by visiting the Grants.gov website.
b. Employer/Taxpayer Number (EIN/TIN): (Required): Enter the Employer
or Taxpayer Identification Number (EIN or TIN) as assigned by the Internal
Revenue Service. If your organization is not in the US, enter 44-4444444.

76

LOW INCOME TAXPAYER CLINIC

13.

14.

15.

16.

Areas Affected By Project: List the areas or entities using
the categories (e.g., cities, counties, states, etc.) specified in
agency instructions. Use the continuation sheet to enter
additional areas, if needed.
Descriptive Title of Applicant’s Project: (Required) Enter
a brief descriptive title of the project. If appropriate, attach a
map showing project location (e.g., construction or real
property projects). For preapplications, attach a summary
description of the project.
Congressional Districts Of: (Required) 16a. Enter the
applicant’s Congressional District, and 16b. Enter all
District(s) affected by the program or project. Enter in the
format: 2 characters State Abbreviation – 3 characters
District Number, e.g., CA-005 for California 5th district, CA012 for California 12th district, NC-103 for North Carolina’s
103rd district. • If all congressional districts in a state are
affected, enter “all” for the district number, e.g., MD-all for all
congressional districts in Maryland. • If nationwide, i.e. all
districts within all states are affected, enter US-all. • If the
program/project is outside the US, enter 00-000.

17.

Proposed Project Start and End Dates: (Required) Enter
the proposed start date and end date of the project.

18.

Estimated Funding: (Required) Enter the amount
requested or to be contributed during the first funding/budget
period by each contributor. Value of in-kind contributions
should be included on appropriate lines, as applicable. If the
action will result in a dollar change to an existing award,
indicate only the amount of the change. For decreases,
enclose the amounts in parentheses.

Low Income Taxpayer Clinics (LITCs) 2011 Interim and Year-End Report
Name of Clinic
Reporting Period

Interim Report - January 1 through June 30, 2011

Report Type

Original Report or

Amended Report

Clinic Type

ESL Clinic

Controversy Clinic

or

Year-End Report - January 1 through December 31, 2011
Both

Does the organization have a pro bono panel

Yes

No

Does the organization provide CLE or CPE tax law training

Yes

No

Does the organization have a U.S. Tax Court agreement

Yes

No

Part I. ESL Activities
1

(i) Interim Report

(ii) Year-End Report

Enter the number of outreach activities conducted during the reporting period.
a. Enter the number of ESL taxpayers who attended outreach activities
during the reporting period.

2

Enter the number of Educational Workshops conducted during the
reporting period.
a. Enter the number of ESL taxpayers who attended Educational Workshops
during the reporting period.

3

Enter the number of Educational Programs conducted during the
reporting period.
a. Enter the number of ESL taxpayers who attended Educational Programs
during the reporting period.

4

Enter the number of direct contacts or one-on-one consultations with ESL
taxpayers during the reporting period.

5

Enter the number of radio or television advertisements / appearances and
newspaper articles during the reporting period.

6

Enter the number of ESL taxpayers referred for controversy representation during
the reporting period.

Return and Other Tax Form Preparation Activities
7

8

Enter the number of returns that were ancillary to ESL outreach and educational
activities. (If providing ESL and controversy services and the preparation of a
return is directly related to a controversy, do not count any such return here.
See Part II, Line 11) 12
Enter the number of Individual Taxpayer Identification Number (ITIN) applications
prepared during the reporting period that were ancillary to ESL outreach and
educational activities.

If your clinic is ESL only, DO NOT complete any other portion of this form for the reporting period.

Part II. Controversy Activities
1

Enter the number of cases that were worked in the previous year that remained
open as of January 1, 2011

2

Enter the number of new cases opened during the reporting period.
 For the Year-End Report, enter the total number of new cases opened
from January 1, 2011 through December 31, 2011.

(i) Interim Report

(ii) Year-End Report

www.irs.gov
Department of the Treasury-Internal Revenue Service
Form 13424-A (Rev. 5-2010) Catalog Number 53040U
(If providing ESL and controversy services and the preparation of an ITIN application is directly related to a controversy, do not count any such
return here. See Part II, Line 13)

77

Name of Clinic

Part II. Controversy Activities (continued)
3

(i) Interim Report

(ii) Year-End Report

Total number of open cases.
 For the Interim Report add lines 1i and 2i.
 For the Year-End Report add lines 1i and 2ii.
For the number of cases reported on line 3 above, complete lines a through i for the reporting period.
a. Enter the number of cases where the taxpayer's income exceeded 250%
of the poverty level during the reporting period.
b. Enter the number of cases where the amount in controversy (tax and penalty)
exceeded $50,000 per taxable year (IRC § 7463) during the reporting period.

Form 13424-B,

c. Enter the number of ALL issues addressed during the reporting period. This
line should equal line 36 on the Supplemental Issues Form.
d. Enter the number of cases where a petition is filed in U.S. Tax Court.
the
e. Enter the number of refund suits filed in U.S. District Court or U.S. Court of
Federal Claims.
a
f. Enter the number of cases where the clinic is working a bankruptcy issue with a tax issue.
g. Enter the number of controversy cases opened for ESL taxpayers.
h. Enter the number of cases referred to a qualified pro bono or other LITC
representative.
i. Enter the number of cases referred to TAS.

4

Enter the number of cases closed during the reporting period.

5

6

Enter the number of consultations during the reporting period that did not result in
representation

6

7

Enter the number of informal consultations in U.S. Tax Court during the
reporting period.
the

7

8

Enter the number of informal consultations in U.S. District Court or U.S. Court of
Federal Claims during the reporting period. a
the

8

9

Enter the number of consultations that did not qualify for clinic services but were
referred to appropriate alternatives such as state bars during the reporting period.

9

10

Enter the number of state income tax matters handled during the
reporting period that were related to a controversy case.

10 11
a

Enter the number of taxpayers assisted during the reporting period, including
those for whom cases were not opened.

Return and Other Tax Form Preparation Activities

11 13

Enter the number of tax returns (including amended returns) that were prepared
by the clinic during the reporting period that were directly related to a controversy.
(If providing ESL and controversy services and the preparation of a return is
ancillary to ESL outreach and educational activities, do not count any such return
here. See Part I, Line 7).

12 14

Enter the number of ITIN applications prepared during the reporting period that
were directly related to a controversy.

Publicity and Outreach Activities
13
14
15

78

15

Enter the number of outreaches conducted during the reporting period.

16

Enter the number of radio or television advertisements / appearances and
newspaper articles during the reporting period.

Form 13424-A (Rev. 5-2010) Catalog Number 53040U

LOW INCOME TAXPAYER CLINIC

www.irs.gov

Department of the Treasury-Internal Revenue Service

APPENDIX C
Instructions for the 2011 Low
Income Taxpayer Clinics Interim
and Year-End Report Form
Note. When submitting your Interim or Annual
Reports package, this form is part of the Program
Narrative.
Under unusual circumstances, clinics may request
an extension of time to submit the Interim Report
package or the Annual Report package. Requests
for an extension must be submitted in writing with a
detailed explanation. Requests should be sent by email to the clinic’s assigned analyst in the LITC
Program Office prior to the due date of the report.
Once received, the analyst will ask the Director of
the Low Income Taxpayer Clinic Program to review
it and make a determination. If the report is
received by the approved extension date it will be
considered timely.
Note. Failure to timely submit required reports to
the LITC Program Office may result in freezing of
funds, reduction of future funds, or termination of
the grant.

Purpose

This form is designed to capture the work the clinic
has performed during the reporting periods. This
form must be completed by both ESL and
Controversy clinics. The LITC program requires
clinics to submit two reports during a grant cycle an Interim report and a Year-End report. These
reports are used by the Program Office to
determine the effectiveness of LITC operations by
reviewing services provided to low income
taxpayers and ESL taxpayers.
Note. Interim and Year-End Reports (including this
report form contained) may be released under the
Freedom of Information Act (FOIA). In response to
a FOIA request, the LITC Program Office will
release these reports after appropriate redactions to
ensure confidentiality of taxpayer information.

Reporting Requirements
ESL Clinics. If your clinic has been funded for ESL
activity only, complete Part I of the form.
Controversy Clinics. If your clinic has been funded
for controversy activity only, complete Part II of the
form.

Both ESL and Controversy. If your clinic has been
funded for both ESL and controversy activities,
complete both Part I and Part II of the form
Reporting period. Check all boxes that apply.
LITCs are required to report on clinic activities twice
during the grant cycle. The grant cycle is January 1
through December 31 for the year in which a grant
award is received. An Interim Report is required for
the period January 1, 2011 through June 30, 2011;
the Year-End Report is required for the period of
January 1 through December 31, 2011.

Specific Instructions
Part I. ESL, Publicity, and Outreach
Activities
Report outreach activities based on the focus of the
outreach. If the outreach is marketed for the ESL
community and it includes information about
controversy services, the outreach should be
counted as an ESL outreach.
Line 1. Report on this line the number of outreach
activities that may include community events such
as fairs, forums, meetings, etc. to inform the public
about clinic services. Clinic service information at
these events can include, but is not limited to,
public speaking, distribution of marketing materials,
and face-to-face conversation.
Line 1a. Report on this line the number of ESL
taxpayers who attended outreach activities.
Line 2. Educational workshops are conducted in a
class-type or lecture setting. Examples could be
community college classes, sessions at local
community centers, or sessions at churches.
Workshops can cover information such as: how to
complete a Form W-4 for withholding, filing
requirements, collection or examination issues, or
how to locate trustworthy tax professionals.
Line 2a. Report on this line the number of ESL
taxpayers who attended educational workshops.
Line 3. Report on this line the number of CPE /
CLE sessions held to recruit pro bono panel
members..
Line 4. Report on this line, the number of direct
contacts and one-on-one consultations. These
typically follow an outreach event or educational
workshop about taxpayer rights and responsibilities.
Direct contacts or consultations are where the clinic
provides specific information on the attendee’s
issue.
1

Instructions for the 2011 Low Income Taxpayer Clinics Interim and Year-End Report Form

79

APPENDIX C
Line 5. List only the number of events, articles and
advertisements on this line. Use the Program
Narrative to provide additional information such as,
the number of potential listeners, viewers and
readers, as well as the frequency of the
advertisements, programs, articles, and any other
information about your publicity efforts.
Line 6. Report on this line the number of ESL
taxpayers referred for controversy representation.

Return and Other Tax Form Preparation
Activities
Line 7. Ancillary means directly related to or
secondary to an ESL outreach or educational
activity. Thus, tax return preparation for an ESL
only clinic should be limited. Taxpayers that need
current year tax return preparation should be
referred to a VITA or TCE site. If the tax return
preparation is connected to a controversy, it is not
considered “ancillary” and should not be reported
on this line; instead, it should be reported in Part II,
line 11.
Line 8. Preparation of ITIN applications is limited to
two contexts: (1) If preparation is necessary to
resolve the taxpayer’s controversy with the IRS, or
(2) If preparation is ancillary to an educational
activity of a taxpayer for whom English is a second
language. Include on this line only the number of
ITIN applications that fit into category (2).

Part II. Controversy Activities

For the purposes of completing this form, a case
means the clinic has entered into an agreement
with the client for representation involving a
controversy with the Internal Revenue Service
(IRS). A case includes all issues for one taxpayer
with whom the clinic enters into a pro bono or clinic
representation agreement, or for whom the clinic
obtains a Form 2848, Power of Attorney (POA) or
other official authorization.
Line 1. Report on this line the number of cases
that were worked in the previous year that remained
open as of January 1. This would only be reported
in column “i,” during the Interim reporting period.
Line 2. Report on this line the number of new
cases opened in the reporting period. A case is also
considered new if the issue was closed in a prior
reporting period and then reopened to provide
additional assistance.

Line 3. Enter the total numbers from lines one and
two.
Line 3a. For information on the poverty guidelines,
see Publication 3319, Section IV. LITC PROGRAM
GRANT REQUIREMENTS.
Line 3b. For cases that exceeded $50,000 you
must explain why the case was accepted and the
circumstances surrounding the representation or
referral in your Program Narrative.
Line 3c. The number on this line should equal line
36 on the Supplemental Issues Form (Form 13424B).
Line 3d Enter the number of cases where a petition
has been filed in the U.S. Tax Court. This may
include cases where the petition was filed prior to
this reporting period but the clinic is still involved
with the litigation during the reporting period.
Line 3e Enter the number of refund suits filed in a
U.S District Court or the U.S. Court of Federal
Claims. This may include cases where the petition
was filed prior to this reporting period but the clinic
is still involved with the litigation during the reporting
period.
Line 3f Enter the number of bankruptcy cases
where the clinic is assisting the client with a tax
issue.
Line 3g Enter the number of controversy cases
opened for ESL taxpayers.
Line 3h. Include on this line the total number of
cases where the clinic entered into a representation
agreement and referred the case to a qualified pro
bono or other LITC representative to assist in
resolution of the case.
Line 3i. Include on this line the total number of
cases where the clinic entered into a representation
agreement and referred to TAS for resolution of the
case.
Line 4. A case is considered closed when the clinic
is no longer in a representation agreement with the
client. This includes cases that were opened with a
representation agreement and then closed due to
non-responsiveness.
Line 5. Consultations are where brief advice or
guidance specific to the taxpayer’s issue is given
but no written representation agreement is entered
into. This can occur either by telephone or in a faceto-face meeting. Do not include consultations that
2

Instructions for the 2011 Low Income Taxpayer Clinics Interim and Year-End Report Form

80

LOW INCOME TAXPAYER CLINIC

occurred in the U.S. Tax Court, a U.S. District
Court, or the U.S. Court of Federal Claims; these
will be included on lines 7, or 8.

Return and Other Tax Form Preparation
Activities

Line 6. Enter on this line all consultations that
occurred in the U.S. Tax Court. For the definition of
consultation, see the instructions for line 5.

Line 11. This includes amended returns and prior
year returns that the clinic prepared during this
period. Taxpayers that need current year tax return
preparation should be referred to a VITA or TCE
site.

Line 7. Enter on this line all consultations that
occurred in a U.S. District Court or the U.S. Court of
Federal Claims. For the definition of consultation,
see the instructions for line 5.
Line 8. Include on this line consultations where the
client did not qualify for LITC services but was
referred to an alternative professional
representative to assist in resolution of the case.
Line 9. Controversy cases can sometimes involve
a state tax matter that must be resolved to move
the federal portion of the case to resolution.
Line 10. For reporting purposes, preparation of a
joint return counts as two taxpayers assisted. If
representation or referral is provided to only one
spouse on a joint return, the number of taxpayers
assisted should be reported as one.
Line 10a. Of the number of taxpayers on line 10,
enter the number of taxpayers that attended a
workshop and as a result became a controversy
client.

Line 12. Preparation of an ITIN application should
only be counted when it is necessary to resolve the
taxpayer’s controversy with the IRS. This includes
the taxpayer’s application and any additional
applications for dependents.

Controversy Publicity, and Outreach
Activities
Report outreach activities based on the focus of the
outreach. If the outreach is marketed to discuss
controversy services and a presentation is included
about ESL community services, the outreach
should be counted as controversy outreach.
Line 13. Outreach activity is when the clinic
informs the public about clinic services by attending
community events, meetings, etc.
Line 14. Enter the number of CPE / CLE sessions
held to recruit pro bono panel members.
Line 15. Do not enter the number of potential
listener/viewers; just report the number of actual
events. The Program Narrative is where you would
reflect the size of the potential listener/viewer
audience.

3
Instructions for the 2011 Low Income Taxpayer Clinics Interim and Year-End Report Form

81

Low Income Taxpayer Clinics (LITCs) 2011 Supplemental Issues
Name of Clinic
Reporting Period

Interim Report - January 1 through June 30, 2011 or

Report Type

Original Report

or

Year-End Report - January 1 through December 31, 2011
For each column, enter the number of issues
worked for the reporting period

Amended Report

Reset Interim Report Fields

Part I. Collection Issues

(i) Interim Report

1

Levies

2

Liens

3

Payments

4

Collection Due Process (CDP)

5

Collection Appeals Process (CAP)

6

Bankruptcy

7

Offers in Compromise (OIC)

8

Installment Agreements (IA)

9

Currently Not Collectible (CNC)

(ii) Year-End Report

Total Collection Issues

10

Part II. Examination Issues
11 Earned Income Tax Credit (EITC)
12 Questionable Tax Return Preparers
13 Other Correspondence Examinations
14 Office or Field Exam (Non-EITC)

Examinations (Non-EITC)

15 Audit Reconsideration
16 Automated Substitute for Return (ASFR)
17 Automated Under Reporter (AUR)

Underreporter (AUR)

18 Amended Returns

Total Examination Issues

19

Part III. Miscellaneous Issues
20 Appeals (not CDP)
21 Refund Claim Claim for Refund or Request for Abatement
22 First-Time Homebuyer Credit
23 Relief from Joint and Several Liability (Innocent Spouse)
24 Injured Spouse Claim
25 IRC § 6672 Trust Fund Recovery Penalty
26 Other Civil Penalties
27 Identity Theft
28 Cancellation of Debt (COD)
29 Individual Taxpayer Identification Numbers (ITINs)
30 Nonfiler
31 Determination of Worker Status (Form SS-8/Form 1099 Misc.)

Total Miscellaneous Issues

32

Part IV. Other Issues
33
34
35 (including issues listed on a separate sheet of paper)

Total Other Issues

Part V. Total Issues Reported
Enter the total number of issues. Add the amounts reported on lines 10, 19, 32, & 35.
36 Enter the total here and on Form 13424-A, the 2010 Low Income Taxpayer Clinics
Interim and Year-End Report, Part II, line 3c.
Form 13424-B (Rev. 5-2009)

Catalog Number 53041F

2010

82

LOW INCOME TAXPAYER CLINIC

www.irs.gov

Department of the Treasury-Internal Revenue Service

update this box to total the column entries

APPENDIX C
Instructions for the 2011 Low
Income Taxpayer Clinics
(LITC) Supplemental Issues
Form
Note: When submitting your Interim or Annual
Report package, this form is part of the Program
Narrative.

the period January 1 through June 30; the
Year-End Report is required for the period of
January 1 through December 31.
Interim reporting period. Complete column “i” for
the reporting period of January 1 through June 30.
In this column, capture all issues currently being
worked that were carried over from the previous
year and any new issues that were worked January
1 through June 30.

Under unusual circumstances, clinics may request
an extension of time to submit the Interim Report
package or the Annual Report package. Requests
for an extension must be submitted in writing by email to the clinic’s assigned program analyst prior to
the due date of the report. Once received, the
analyst will ask the Director of the Low Income
Taxpayer Clinic Program to review it and make a
determination.

Year-End reporting period. Complete column “ii”
reporting issues for the period January 1 through
December 31. Column “i” should have the totals
previously reported for the interim reporting period
and column “ii” will be completed reflecting the total
activity that occurred during the reporting period of
January 1 through December 31. In this column,
capture all issues worked for the year by adding
column “i” to the number of new issues worked July
1 through December 31.

Note: Failure to timely submit required reports to
the LITC Program Office may result in freezing of
funds, reduction of future funds, or termination of
the grant.

Specific Instructions

Purpose

The Supplemental Issues Form is used by
Controversy LITCs to report clinical work on some
of the most common tax issues and captures the
type of assistance provided to taxpayers.
Note: Interim and Year-End Reports (including the
report forms contained in Appendix C) may be
released under the Freedom of Information Act
(FOIA). In response to a FOIA request, the LITC
Program Office may release these reports after
appropriate redactions to ensure confidentiality of
taxpayer information.

Reporting Requirements

Who should complete the Supplemental Issues
Form?
The Supplemental Issues Form is to be completed
by any clinic reporting cases in Part II. Controversy
Activities of the Low Income Taxpayer Clinics
Interim and Year-End Report. This form must be
attached to the Low Income Taxpayer Clinic (LITC)
Interim and Annual Report packages for each
reporting period.
Reporting period. Check all boxes that apply.
LITCs are required to report on clinic activities twice
during the grant cycle. The grant cycle is January 1
through December 31 for the year in which a grant
award is received. An Interim Report is required for

Parts I, II and III
For each issue listed in Parts I, II, and III, provide
the total number of issues worked during the
reporting period. Cases can involve more than one
issue and each issue that the clinic is actively
working should be reported separately.
Example 1: Organization A worked ten cases
between January 1 and June 30. Each case has
three issues - levy, installment agreement, and nonfiler. To complete this form Organization A would
enter “10” on lines 1, 8, and 30.
Example 2: Organization B worked a levy case
that developed a CDP issue. The issues in this
case would be counted on lines 1 and 4.
Example 3: Organization A worked with a client
who needed an installment agreement but also had
a lien filed. The client does not have issue with the
federal tax lien and the clinic is not actively trying to
resolve the lien issue. The installment agreement
issue would be counted however, the lien issue
would not.

Parts I. Collection Issues
Counting an Issue. During the course of working a
case count each issue once as it is identified and
worked.
Line 1. Levies. Report on this line the number of
issues worked during the reporting period where
you assisted taxpayers with any levy issue,

Instructions for the Low Income Taxpayer Clinics (LITC) 2011 Supplemental Issues Form

1

83

APPENDIX C
including a notice of intent to levy, getting a release
of levy, or getting a return of levied funds.
Line 2. Liens. Report on this line the number of
issues worked during the reporting period where
you assisted taxpayers with a lien issue, including a
notice of lien, a discharge of lien, a subordination of
lien, withdrawal of a lien, certificates of nonattachment, or a release of lien.
Line 3. Payments. Report on this line the number
of issues during the reporting period where you
assisted taxpayers with a payment issue, including
a lost payment, tracing a payment, or making a
payment.
Line 4. Collection Due Process (CDP). Report on
this line the number of issues worked during the
reporting period where you assisted taxpayers with
a collection due process issue.
Line 5. Collection Appeals Program (CAP).
Report on this line the number of issues worked
during the reporting period where you assisted
taxpayers with any collection appeals issue.
Line 6. Bankruptcy. Report on this line the
number of issues worked during the reporting
period where you assisted taxpayers with any taxrelated bankruptcy issue, including a discharge of
bankruptcy or notifying the IRS of bankruptcy
status.
Line 7. Offers in Compromise (OIC). Report on
this line the number of issues worked during the
reporting period where you assisted taxpayers with
an OIC issue, including submission of an OIC, the
processing of an OIC or the rejection of an OIC.
Line 8. Installment Agreements (IA). Report on
this line the number of issues worked during the
reporting period where you assisted taxpayers with
an installment agreement issue, including a request
for an IA, the denial of an IA, or default of an IA.
Line 9. Currently Not Collectible (CNC). Report
on this line the number of issues worked during the
reporting period where you assisted taxpayers with
a CNC issue, including a request for CNC status or
working with the IRS to ensure the account is
correctly coded for CNC status.
Line 10. Total Collection Issues. Add lines 1
through 9.

Part II. Examination Issues
Counting an Issue. During the course of working a
case count each issue once as it is identified and
worked.
Line 11. Earned Income Tax Credit (EITC).
Report on this line the number of issues worked
during the reporting period where you assisted
taxpayers with an EITC Examination issue
(correspondence exam or field exam) including
EITC Certification and EITC Recertification issues.

LOW INCOME TAXPAYER CLINIC

Deleted: period,

Line 12. Questionable Tax Preparer Issues.
Report on this line the number of issues worked
during the period where you provided assistance to
taxpayers as a result of the practices by
questionable tax preparers.
Line 13. Other Correspondence Examinations
(non-EITC) Report on this line the number of issues
worked during the reporting period where you
assisted taxpayers with a correspondence exam
issue other than an EITC Exam, EITC Certification,
or EITC Recertification. Office or field examination
issues should be reported on line 14.
Line 14. Office or Field Examinations (nonEITC). Report on this line the number of issues
worked during the reporting period where you
assisted taxpayers with an office or field
examination. An office or field examination involves
a face-to-face meeting with an examiner or revenue
agent. Examinations conducted through
correspondence from an IRS campus are reported
on line 13.

Deleted: period,

Deleted: period,

Deleted: period,
Deleted: period,

Deleted: period,

Deleted: period,
Deleted: period,

Deleted: period,

Line 15. Audit Reconsideration. Report on this
line the number of issues worked during the
reporting period where you assisted taxpayers with
an audit reconsideration. An audit reconsideration is
an IRS procedure designed to help taxpayers when
they disagree with the results of an audit of their tax
return or a return the IRS created for taxpayers
because they did not file a tax return. This process
allows the IRS to reconsider a taxpayer’s
information informally.
Line 16. Automated Substitute for Return
(ASFR). Report on this line the number of issues
worked during the reporting period where you
assisted taxpayers with an ASFR assessment
issue. This typically involves issues where the IRS
determines the correct tax liability by computing tax,
penalties, and interest, based upon Information
Reporting Program (IRP) information submitted by
payors, combined with other internally available
information.

Instructions for the Low Income Taxpayer Clinics (LITC) 2011 Supplemental Issues Form

84

Deleted: period,

2

Deleted: period,

Deleted: period,

Deleted: period,
Deleted: period,

Line 17. Automated Underreporter (AUR).
Report on this line the number of issues worked
during the reporting period where you assisted
taxpayers with an Automated Underreporter (AUR)
Program issue. Taxpayers are typically notified of
an AUR issue through CP 2000 notices. This
process is part of the Information Reporting
Program, where the IRS matches third-party
information returns to identify income and
deductions that do not appear to be reported on tax
returns.
Line 18. Amended Returns. Report on this line
the number of issues worked during the reporting
period where you assisted taxpayers with a Form
1040X issue. Form 1040X is used to change the
original return to include new information. (A filed
return can include an SFR or an original return).
Line 19. Total Examination Issues. Add lines 11
through 18.

Part III. Miscellaneous Issues
Counting an Issue. During the course of working a
case count each issue once as it is identified and
worked.
Line 20. Appeals. Report on this line the number
of issues worked during the reporting period where
you assisted taxpayers with an Appeals conference
or hearing, except for CDP issues (report these on
line 4) or CAP issues (report these on line 5).
Line 21. Claim for Refund or Request for
Abatement. Report on this line the number of
issues worked during the reporting period where
you assisted taxpayers with a Form 843 issue.
Form 843 is used to claim a refund or request an
abatement of certain taxes, interest, penalty and
additions to tax.
Line 22. First-Time Homebuyer Credit. Report on
this line the number of issues worked during the
reporting period where you assisted taxpayers with
any First-Time Homebuyer Credit issue.
Line 23. Relief from Joint and Several Liability
(Innocent Spouse). Report on this line the number
of issues worked during the reporting period where
you assisted taxpayers with any innocent spouse
relief issue, whether the relief was granted or not.
Do not include on this line Injured Spouse issues;
these issues should be reported on line 24.
Line 24. Injured Spouse Claim. Report on this
line the number of issues worked during the
reporting period where you assisted taxpayers with
an injured spouse claim or issue. When a joint

return is filed and the refund is applied toward the
one spouse’s past due debt and the other spouse
(injured spouse) is not legally liable; the spouse
who is not liable is the injured spouse.

Deleted: period,

Line 25. IRC § 6672 Trust Fund Recovery
Penalty. Report on this line the number of issues
worked during the reporting period where you
assisted taxpayers with Trust Fund Recovery
Penalty (TFRP) issues. The TFRP is a penalty
provided by IRC section 6672 against any person
required to collect, account for, and pay over taxes
held in trust who willfully fails to perform any of
these activities.

Deleted: period,

Line 26. Other Civil Penalties. Report on this line
the number of issues worked during the reporting
period where you assisted taxpayers with other civil
penalties issues. Civil penalties can be assessed in
several instances including, for failure to timely file
a federal tax return, substantial understatement of
tax, understating a reportable transaction, filing an
erroneous claim for refund or credit, filing a frivolous
tax submission, or failing to supply an SSN or
individual taxpayer identification number.
Line 27. Identity Theft. Report on this line the
number of issues worked during the reporting
period where you assisted taxpayers who selfidentified themselves as a victim of identity theft or
received a letter or notice from the IRS that leads
them to believe someone has used their social
security number.

Deleted: period,

Deleted: period,
Deleted: period,

Line 28. Cancellation of Debt (COD). Report on
this line the number of issues worked during the
reporting period where you assisted taxpayers with
a debt that was either cancelled or forgiven. This
amount may be taxable depending on the
circumstances.

Deleted: period,
Deleted: period,

Line 29. Individual Taxpayer Identification
Numbers (ITINS). Report on this line the number of
issues worked during the reporting period where
you assisted taxpayers with the preparation or
processing of ITIN applications.
Line 30. Nonfiler. Report on this line the number
of issues worked during the reporting period where
you assisted taxpayers who had a filing requirement
for a previous year but failed to file their tax
return(s).
Line 31. Determination of Worker Status (Form
SS-8/Form 1099 Misc.). Report on this line the
number of issues worked during the reporting
period where you assisted taxpayers with employee
vs. independent contractor issues.

Instructions for the Low Income Taxpayer Clinics (LITC) 2011 Supplemental Issues Form

Deleted: period,

Deleted: period,
Deleted: period,

Deleted: period,
Deleted: period,

Deleted: period,
Deleted: period,

3

85

Line 32. Total Miscellaneous Issues. Add lines
20 through 31.

Part IV. Other Issues
Counting an Issue. During the course of working a
case count each issue once as it is identified and
worked.
For issues not listed on this form, indicate the
specific issue and the number of issues during the
reporting period that the issue was worked. If
additional space is needed, attach a separate sheet
of paper listing the reporting period the issue, and
the number of issues the issue occurred. At the top
of the separate sheet, identify your organization and
the reporting period.

Deleted: period,

Line 33. Report on this line an issue that was not
listed in Parts I, II, and III.
Line 34. Report on this line an issue that was not
listed in Parts I, II, and III.
Line 35. Total Other Issues. Add lines 33, 34 and
the total of issues reported on the separate sheet of
paper, if applicable.

Instructions for the Low Income Taxpayer Clinics (LITC) 2011 Supplemental Issues Form

86

LOW INCOME TAXPAYER CLINIC

4

APPENDIX C
Low Income Taxpayer Clinics (LITCs)
Advocacy Information
Reporting Period: € Interim Report - January 1 thru June 30, 2011 or € Year-End Report - January 1 thru December 31, 2011

Clinic Name:

Part I. Systemic Advocacy Submissions:
Complete the following section to identify issues submitted to educate or advocate for low income or ESL taxpayers on the
Systemic Advocacy Management System (SAMS) http://www.irs.gov/advocate/article/0,,id=117703,00.html .
Issue Number:

Submitter:

Date Submitted:

Submitter:

Date Submitted:

Submitter:

Date Submitted:

Submitter:

Date Submitted:

Issue Description (brief):

Issue Number:
Issue Description (brief):

Issue Number:
Issue Description (brief):

Issue Number:
Issue Description (brief):

Part II. Published Materials:
Complete the following section to identify articles written to educate or advocate for low income or ESL taxpayers.
Source:

€ Book

€ Law Review

€ Magazine

€ Newspaper

€ Website € Other ____________________

Author’s Name:

Date Published:

Article Title:

Publication / Website: _________________________

Article Description (brief):

Source:

€ Book

€ Law Review

€ Magazine

€ Newspaper

€ Website € Other ____________________

Author’s Name:

Date Published:

Article Title:

Publication / Website: _________________________

Article Description (brief):

Source:

€ Book

€ Law Review

€ Magazine

€ Newspaper

€ Website € Other ____________________

Author’s Name:

Date Published:

Article Title:

Publication / Website: _________________________

Article Description (brief):

Form 13424-C

87

SAMPLE

Volunteer / Pro Bono Time Reporting Form

Per OMB A-110, LITCs are required to track the amount of time volunteers spend working on LITC activities. Use this form to document the
amount of time volunteers or pro bono members use to resolve a client’s issue(s).
Volunteer’s Name: Joe Smith
Activity
Date

Case ID

Activities and Time Reporting

(if
applicable)
Consult
with
client

Ex. 3/14/10

Total

02345BA

Represent
before the IRS
(meeting,
phone call, etc)

Represent
in Court

Prepare
IRS Appeal

Research

.5hr

2.0hrs

.5hr

2.0hr

LITC Volunteer Pro Bono Time Reporting

88

Court
Filing

LOW INCOME TAXPAYER CLINIC

Translation

Outreach

Clerical
assistance

Return
Prep

Intake

Educating

Revision 3/14/10

INDEX

Term

90/250 Requirement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Internal Controls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Additional Funding Request . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Laws and Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Amount in Controversy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

LITC Conference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Ancillary Tax Return Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

LITC Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Annual Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

LITC Program Office . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Report Form . . . Appendix C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

LITC Program Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Contents of 26, Appendix B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Lobbying Restrictions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Matching Funds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Assembly of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Ineligible Funds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Background Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Qualified Funds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Budget/Financial Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Mentoring Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Civil Rights Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Name or Organization Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Networking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Continuing Multi-Year Grant Applications . . . . . . . . . . . . . . . . . . . 1

Nominal Fee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Determination of Program Performance . . . . . . . . . . . . . . . . . . . . 1

Office of Professional Responsibility . . . . . . . . . . . . . . . . . . . . . . . . 1

Electronic Application Website . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

OMB Circulars/Requirements8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

New or Single-Year Grant Applications . . . . . . . . . . . . . . . . . . . . . 1

Operational Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Where and When to File . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Outreach/Publicity Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Audit Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Payments to LITC Grantees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Civil Rights Reporting Requirements . . . . . . . . . . . . . . . . . . . . . . . . 1

Poverty Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Clinic, defined . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Pro Bono Panel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Clinic Director . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Qualified Business Administrator (QBA) . . . . . . . . . . . . . . . . . . . . 1

Confidentiality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Qualified Representative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Continuing Professional Education (CPE) . . . . . . . . . . . . . . . . . . . 1

Qualified Tax Expert (QTE) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Controversy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Qualified Volunteers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Controversy Clinic Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Recordkeeping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Deobligating Funds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Referral Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Determination of Program Performance . . . . . . . . . . . . . . . . . . . . . 1

Reporting Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Documentation of Matching Funds Sources . . . . . . . . . . . . . . . . . 1

Site Assistance Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

ESL Activities/Clinic Requirements . . . . . . . . . . . . . . . . . . . . . . . . . 1

Standards of Operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Start-up Expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Allowable Expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Student Power of Attorney . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Unallowable Expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Supplemental Issue Form . . . Appendix C . . . . . . . . . . . . . . . . . . . . 1

Family Unit, defined . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Tax Compliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Fees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Tax Information Authorization Form . . . Appendix A . . . . . . . . . . 1

Grant Agreement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Tax Library . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Grant Application Forms Appendix A . . . . . . . . . . . . . . . . . . . . . . . 1

Tax Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Grantee Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Trafficking Victims Protection Act of 2000 . . . . . . . . . . . . . . . . . . 1

Income, defined . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Unused Funds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Interim Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Withdrawal from Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Contents of 24, Appendix B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Workgroup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Report Form . . . Appendix C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Volunteer Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

89

$+ffi
ff$

+#fiH
fffi

g +*****

i:iiiti:i,i,fiit

;$iilll.]i

fiiiiffi
iii'Hltiiii"ll;rrirri;;:rir;:!,f;irjil$iXiiri#iil$tLj+:r:
irlillijiii,r+iliit:riii

iiirii:+iiliii

.1i

OMB Number:4040-0004
ExoirationDate: 01/31/2009

Version02

Application for Federal Assistance SF424
" 1. Typeof Submission:
Preapplication

n

l-l Application
f,

Application
Changed/Corrected

3 Date Received:

" 2 Type of Application:

- lf Revision,selectappropriateletter(s):

!tte w
!

Continuation

I

Revision

" Other (Speciff)

4 Applicantldentifier:

. 5b FederalAward ldentifier

5a. FederalEntity ldentifier:

State Use Only:
6. Date Received by State

7. State Applicationldentifier:

8. APPLICANT INFORMATION:
" a. Legal
^"r",

I
I

* c. Organizational
DUNS:

ldentificationNumber(ElN/TlN):
b. Employer/Taxpayer

d. Address:
Streetl:
Street2:
City:
County:
State:
Province:
Country:

U SA:

U N IT ED

ST AT ES

Zip / PostalCode:
e. Organizational Unit:
DeoarlmentName:

DivisionName:

f' Nameand contact informationof personto be contactedon mattersinvolvingthis application:
Prefix:

" FirstName:

Middle Name:
* Last Name:
Suffix:
Title:
OrganizationalAffiliation:

- TeleohoneNumber:

" Er"il,

Fax Number:

OMB Number:4040-0004
ExpirationDate: 01/31/2009

Assistance SF424
Application for Federal
,-rO"

Type:
of Applicant1: SelectApplicant

rvneofAonri9112:
1g1Yric11lY99
rylg
rypeofApplicantj-Se|""tJllfant

AgencY:
" 10. Name of Federal

Number:
of FederalDomesticAssistance

a.
"",",on
CFDA Title:

Number:
1 3. Competition ldentification

I

(Cities' Counties' States' etc'):
14. Areas Affected by Project

* 15, Descriptive Title of Applicant's

in agencyinstructions
Attach supportingdocumentsas specified

I

OMB Number:4040-0004
ExoirationDate: 01/31/2009

Version02

Appfication for Federal Assistance 5F424
16. CongressionalDistrictsOf:
' a. Applicant

- b. Program/Prolect

Attach an additional list of Program/ProjectCongressionalDistricts if needed

. b. End Date:
18. Estimated Funding ($):
a Federal
b. Applicant
c. State
d. Local
e. Other
f. ProgramIncome
g. TOTAL

. 19. ls ApplicationSubjectto ReviewBy StateUnderExecutiveOrder12372Process?
!

a. This applicationwas madeavailableto the Stateunderthe ExecutiveOrder12372Processfor reviewon

l-1 b. erogramis subjectto E.O.12372but has not beenselectedby the Statefor review.
El c. Programis not coveredby E.O.12372.
* 20. ls the Applicant Delinquent On Any Federal Debt? (lf "Yes", provide explanation.)

lves

E*o

21. *By signing this application,I certify (1) to the statementscontainedin the list of certifications*'and (2) that the statements
herein are true, complete and accurateto the best of my knowledge.I also providethe requiredassurances**and agree to
comply with any resultingterms if I acceptan award.I am awarethat any false,fictitious,or fraudulentstatementsor claims may
subject me to criminal,civil, or administrativepenalties.(U.S.Code,Title218,Section1001)

[

.. r ncn e r

*' The list of certiflcationsand assurances,or an internetsite where you may
obtain this Iist, is containedin the announcementor agency
soecificinstructions.
Authorized Representative:
Prefix:

* FirstName:

I

M idd l eN a m e :
* Last Name:
Suffix:
* Tifle:

TelephoneNumber: |

| Fax Number:

'Em a i l :
Signatureof AuthorizedRepresentative:
Authorized for Local Reproduction

Date Signed:

Standard F otm 424 (Revised 10/2005)
Prescribedby OMB CircularA-102

OMB Number:4040-0004
ExoirationDate: 01/31/2009

Appfication for Federal Assistance 5F424
* Applicant Federal Debt Delinquency Explanation
Maximum number of
The following field should contain an explanationif the Applicantorganizationis delinquenton any Federal Debt
characters thit can be entered is 4,000. iry and avoid extra spaces and carriage returns to maximizelhe availabilityof space.

Version 02

INSTRUCTIONSFORTHE SF.424
is estimatedto average60 minutesper response,includingtime tor reviewinginstructions,
Publicreportingburdenfor this collectionof information
Send
the dataneeded,and completing
and reviewingthe collectionof information.
searchingexistingdata sources,gatheringand maintaining
includingsuggestions
for reducingthis burden,to the
commentsregardingthe burdenestimateor any otheraspectof this collectionof information,
Office of Managementand Budget,PaperworkReductionProject(m.A-004i1),Washington,DC 20503.
AND BUDGET,SENDIT TO THE ADDRESS
PLEASE DO NOT RETURNYOURCOMPLETEDFORMTO THE OFFICEOF MANAGEMENT
PROVIDEDBY THE SPONSORINGAGENCY.
This is a standardform (including the continuationsheet)requiredfor useas a cover sheetfor submissionofpreapplicationsand applicationsand
related information under discretionaryprograms. Someof the items are requiredand someare optional at the discretionof the applicantor the
Federalagency(agency).Requireditems are identified with an asteriskon the form and are specifiedin the instructionsbelow. In addition to the
instructionsprovided below, applicantsmust consult agencyinstructionsto determinespecificrequirements.
Item

2.

Entry:
Type of Submission: (Required):
Selectone type of submissionin
accordancewith agency instructions.
. Preapplication
. Application
. unangeo/uorrecreo
AppilGalron
- rr requesleooy lne agency,cnecKrrrnrs
Unless
submissionis to changeor correcta previouslysubmittedapplication.
requestedby the agency,applicantsmay not use thisto submitchangesafter
the closingdate.

NameOf FederalAgency:(Required)Enterthe nameof
the Federalagencyfrom which assistanceis being
requestedwiththis application,

11

uararog (Jr Feoeraruomesuc Assrstance Numoer t tue:
Enterthe Catalogoi FederalDomesticAssistancenumber
andtitleof the programunderwhichassistanceis
requested,as foundin the programannouncement,
if
applicable.
FundingOpportunityNumber/Title:(Required)Enterthe
FundingOpportunity
Numberandtitleof the opportunity
underwhichassistanceis reouested.as foundin the
Drooramannouncement.
CompetitionldentilicationNumber/Title:Enterthe
Competition
ldentification
Numberand titleof the
competition
underwhichassistanceis requested,if
applicable.

Type ol Application: (Required)Selectone type of applicationin accordance 't2.
with agencyinstructions.
. New - An applicationthat is beingsubmittedto an agencyfor the firsttime.
. Continuation- An elitensionfor an additionalfunding/budget
periodfor a
project with a projectedcompletiondate. This can includerenewals.
. Revision- Any changein the FederalGovernment's
financialobligationor
contingentliabilitytrom an existingobligation.lf a
revision,enterthe appropriatelette(s). Morethan one may be
selected.lf "Other"is selected,pleasespecifyin text box provided.
A. IncreaseAward
B. DecreaseAward
C. IncreaseDuration
D. DecreaseDuralion
E. Other (specify)

e

Date Received:Leavethis fieldblank.This datewillbe assignedby the
Federalagency.

4

Applicant ldentifier: Enterthe entityidentifierassignecl
buy the Federal
agency,if any,or the applicant'scontrolnumberil applicable.

5a.

FederalEntity ldentifier:Enterthe numberassignedto your
organizationby the FederalAgency,if any.

5b.

FederalAward ldentifier:For newapplications
leaveblank.For a
continuationor revisionto an existingaward,enterthe previouslyassigned
Federalawardidentifiernumber.lf a changed/corrected
application,
enterthe
Federalldentifierin accordancewithaoencvinstructions.
Date Receivedby State: Leavethis fieldblank.Thisdatewillbe assignedby
the State,if applicable.

6.

Item Entry:
10.

te

14.

Areas Aflected By Project: Listthe areas or entitiesusing
the categories(e.9.,cities,counties,states,etc.)specifiedin
agencyinstructions.
Usethe continuation
sheetto enter
additionalareas,if needed.

15.

Descriptive
Titleof Applicant's
Proiect:(Required)
Enter
a briefdescriptive
titleof theproject.lf appropriate,
attacha

lo.

propertyprojects).For preapplications,attach a summary
descriotion
of the oroiect.
CongressionalDistricts Of: (Required)16a. Enterthe
applicant's
Congressional
District,and | 6b. Enterall
District(s)
affectedbv the orooramor oroiect Enterin the
{ormat:2 charactersState Abbreviation- 3 characters
DistrictNumber,e.9.,CA-005for Californiasthdistrict,CA12th
012for CaliJornia
district,
NC-103for NorthCarolina's
103,0district.. lf all conoressional
districtsin a stateare
affected,enter"all"for the districtnumber,e.9.,MD-allfor all
congressional
districtsin Maryland.. lf nationwide,i.e. al
rlictri.tc

8.

within

all qt2faq

pntar

2rp

I lS-all

. lf ihp

^lfqelod

SIaIe Appilcalron roenlriler: Leave Inrs rero oranK. rnrs roenlrilerwilr oe
assigned by the State, if applicable.

program/project
is outsidethe US, enter00-000.

Applicant lnformation:Enterthe tollowingin accordance
withagency
instructions:
a. Legal Name:(Required):Enterthe legalnameof applicantthatwill
has
undertakethe assistanceactivity.This is ththatthe organization
registeredwith the CentralContractorRegistry.Informationon registeringwith
CCR may be obtainedby visitinqthe Grants.qovwebsite.
Enterthe Employer
b. Employer/TaxpayerNumber (ElN/TlN):(Required):
Number(ElN or TIN)as assignedby the Internal
or Taxpayerldentification
RevenueService. lf your organization
is not in the US, enler44-4444444.

1a

Proposed Proiect start ancl End Dates: (Required)Enter
the proposedstartdate and end date of the project.

18.

EstimatedFunding: (Required)Enterthe amount
requestedor to be contributed
duringthe firstfunding/budget
periodby eachcontributor.
Valueof in-kindcontributions
lines,as applicable.lf the
shouldbe includedon appropriate
actionwillresultin a dollarchangeto an existingaward,
indicateonlythe amountof the change.For decreases,
enclosethe amountsin oarentheses.

DUNSor
c. OrganizationalDUNS:(Required)Enterthe organization's
on obtaining
numberreceivedfrom Dun and Bradstreet.Information
website.
a DUNSnumbermay be obtainedby visitingthe Grants.gov

completeaddressas follows:Streetaddress(Line1
required),City (Required),
County,State(Required,if countryis US),
ZiplPostalCode(Required,
if countryis US).
Province,Country(Required),

e, OrganizationalUnit: Enterthe nameof the primaryorganizational
unit
(anddepartmentor division,(if applicable)
that will undertakethe assistance
activity,if applicable.

contact information of person to be contacted on matters
involving this applicat required),organizational
affiliation(il affiliatedwlthan
organizationotheron: Enterthe name(Firstand last namethanthe applicant
organization),
telephonenumber(Required),
fax number,and emailaddress
(Required)of the personto contacton mattersrelatedto this application.

ype ot Applicant:(Required)Selectup to threeapplicanttype(s)in
accordancewith agencyinstructions.

B . CountyGovernment
City or Township
Government
D. SpecialDistrictGovernment
E . RegionalOrganization
F . U.S. Territoryor Possession
/: IndependentSchoolDistrict
H. Public/StateControlled
Institutionof Higher
Education
Indian/Native
American
TribalGovernment
(FederallyRecognized)
Indian/Native
American
TribalGovernment(Other
than FederallyRecognized)
IndianiNative
American
TriballyDesignated
Organization
Public/lndian
Housing
Authoritv

N.

o.
P.

R.
S.
T.

Nonprofit
PrivateInstitution
of
HigherEducation
lndividual
For-ProfitOrganization
(OtherthanSmall
Business)
SmallBusiness
Hispanic-serving
lnstitution
Historically
Black
Collegesand
(HBCUS)
Universities
TriballyControlled
Collegesand
(TCCUS)
Universities
AlaskaNativeand
NativeHawaiianServing
Institutions
(non-US)
Non-domestic
Entity
Other(specify)

ls ApplicationSubiectto Reviewby State
Executive Order '12372Process? Applicantsshould
contactthe StateSinglePointot Contact(SPOC)for Federal
ExecutiveO,det 123721odeterminewhetherthe application
is subjectto the Stateintergovernmental
reviewprocess.
Selectthe appropriatebox. lf "a." is selected,enter the date
the aoolication
was submittedto the State.
(Required)
box. This questionapplies
Selectthe appropriate
notthe personwho signsas
to the applicantorganization,
the authorizedreoresentative.
Cateooriesof debt include
loarisand taxes.lf yes,
delinquentauditdisallowances,
includean exolanation
on the continuation
sheet.
AuthorizedRepresentative:(Required)To be signedand
datedby the authorizedrepresentative
ot the applicant
organization.
Enterthe name(Firstand last namerequired)
title(Required),
telephonenumber(Required),
fax number,
and emailaddress(Required)
of the personauthorizedto
signlor the applicant.A copyof the governingbody's
for you to signthis applicationas the official
authorization
representative
mustbe on file in the applicant'soffice.
(CertainFederalagenciesmay requirethat this
authorization
be submittedas partof the application.)

OMB ApprovalNo 0348-0044

Non-Construction
BUDGETINFORMATION'
A. BUDGETSUMMARY
SECTION
t

Newor RevisedBudget

Funds
Unobligated
Estimated

$

$

$

Total

Non-Federal
(f)

Federal
(e)

Non-Federal
(d)

Federal
{ c)

iD

(o)

$

o.oo

I

0.00

2.

0.00
J.

0.00

4.
5.

Totals

$

o.oo$

o,oo$

o.oo$

o.oo$

o.oo

SECTIONB. BUDGETCATEGORIES
Total

GRANT PROGRAM. FUNCTION OR ACTIVITY

6. ObjectClass Categories

a. Personnel

(11

(2)

(3)

D

$

$

fs)

$

0.00

b, FringeBenefits

0.00

c. Travel

0.00

d. Equipment

0.00

e. Supplies

000

f. Contractual

0.00

g. Construction

0.00

h. Other

0.00

0.00

0.00

0.00

0.00

i. TotalDirectCharges(sumof 6a'6h)

0.00

j. IndirectCharges
k. TOTALS(sumof 6i and 6i)

o.oo

$

$
o.oo

$

o.oo

oool$

ooo

$

o.oo

-l*
7. Programlncome

s

U

$

Authorizedfor Local Reproduction
Previous Edition Usable

$

o oo
Standard Form424A (Rev 7-97)
Prescribed by OMB Circular A-102

q

RESOURCES
SECTIONC. NON.FEDERAL
(c) State
(b)Applicant

(a)GrantProgram
8.

I

$

(e) TOTALS

(d) OtherSources

0.00

$

l.

0.00

10,

0.00

11

0.00

12.TOTAL(sumof lines8-11)

o.oo$

o.oo$

$

o.oo$

o.oo

CASHNEEDS
SECTIOND. FORECASTED
13. Federal

$

14.Non-Federal

2nd Quarter

1st Quarter

Total for 1st Year

0.00 q

4th Quarter

3rd Quarter

s

ID

0.00 $

0,00 $

s

0.00

15.TOTAL(sumof lines13and 14)

g

0.00 $

0.00

$

OF FEDERALFUNDSNEEDEDFORBALANCEOF THE PROJECT
E. BUDGETESTIMATES
SECTION
(Years)
PERIODS
FUTUREFUNDING
(a) GrantProgram
(d)
Third
{b)First
{c) Second
16,

o,oo

(e) Fourth
$

$

17.
18.
19.
20,TOTAL(sumof lines16-19)

$

0.00 $

o.oo$

o.oo $

0.oo

F. OTHERBUDGETINFORMATION
SECTION
21.DirectCharges:

Charges:
22. Indirect

23. Remarks:
Authorized for Local Reproduction

Standard Form424A (Rev. 7-97) Page 2

FORTHE SF424A
INSTRUCTIONS
Public reportingburdenfor this collectionof informationis estimatedto average180 minutesper response,includingtime for
the data needed,and completingand reviewingthe collection
instructions,
searchingexistingdata sources,gatheringand maintaining
information.Send commentsregardingthe burdenestimateor any otheraspectof this collectionof information,includingsuggestions
Washington,DC 20503.
reducingthis burden,to the Officeof Managementand Budget,PaperworkReductionProject(0348-0044),

AND BUDGET.
PLEASEDO NOT RETURNYOURCOMPLETEDFORMTO THE OFFICEOF MANAGEMENT
AGENCY.
D IT TO THE ADDRESSPROVIDEDBY THE SPONSORING
General Instructions
This form is designedso that applicationcan be made for funds
from one or more grant programs. ln preparingthe budget,
which
adhereto any existingFederalgrantoragencyguidelines
prescribe how and whether budgeted amounts should be
separatelyshown for differentfunctionsor activitieswithin the
program. For some programs, grantor agencies may require
budgetsto be separatelyshown by functionor activity.For other
programs,grantoragenciesmay requirea breakdownby function
or activity. Sections A, B, C, and D should include budget
estimates for the whole project except when applying for
assistance which requires Federal authorizationin annual or
otherfundingperiodincrements.In the lattercase,SectionsA, B,
C, and D should providethe budget for the first budget period
(usually a year) and Section E should present the need for
Federal assistance in the subsequent budget periods. All
applicationsshould contain a breakdownby the object class
categoriesshown in Linesa-k of SectionB.

For continuinggrant program applications, submit these forms
beforethe end of each fundingperiodas requiredby the grantor
agency.Enterin Columns(c) and (d) the estimatedamountsof
funds which will remain unobligatedat the end of the grant
fundingperiodonly if the Federalgrantoragency instructions
providefor this. Otherwise,
leavethesecolumnsblank.Enterin
columns (e) and (f) the amounts of funds needed for the
upcomingperiod.The amount(s)in Column (g) should be the
sum of amountsin Columns(e) and (f),
grants and changes to existinggrants, do not
For supplemental
use Columns(c) and (d). Enterin Column(e) the amountof the
increaseor decreaseof Federalfunds and enterin Column(f) the
amount of the increaseor decreaseof non-Federalfunds. In
Column (g) enter the new total budgetedamount (Federaland
non-Federal)which includes the total previous authorized
the amounts
budgetedamountsplus or minus,as appropriate,
shown in Columns(e) and (f). The amount(s)in Column (g)
shouldnotequalthe sum of amountsin Columns(e) and (f).

SectionA. Budget SummaryLines 14 Golumns(a) and (b)
Line 5 - Showthe totalsfor all columnsused.
For applicationspertainingto a single Federalgrant program
(FederalDomesticAssistanceCatalognumber)and not requiring
a functionalor activitybreakdown,enteron Line 1 underColumn
(a) the Catalogprogramtitle and the Catalognumberin Column
(b ).
For applicationspertainingto a single programrequiringbudget
amounts by multiplefunctionsor activities,enter the name of
each activityor functionon each line in Column(a), and enterthe
Catalognumber in Column (b). For applicationspertainingto
multiple programs where none of the programs require a
breakdownby functionor activity,enterthe Catalogprogramtitle
on each line in Column(a) and the respectiveCatalognumberon
each linein Column(b).
For applicationspertainingto multiple programswhere one or
more programs require a breakdown by function or activity,
prepare a separate sheet for each program requiring the
breakdown.Additional sheets should be used when one form
does not provide adequate space for all breakdownof data
required.However,when more than one sheetis used,the first
page shouldprovidethe summarytotalsby programs.
Lines 14, Columns (c) through (g)
For new applications,leave Column (c) and (d) blank. For each
line entry in Columns(a) and (b), enterin Columns(e), (f), and
(g) the appropriateamounts of funds needed to support the
projectfor the first fundingperiod(usuallya year).

Section B Budget Gategories
In the column headings(1) through(4), enter the titles of the
same programs,functions,and activitiesshown on Lines 1-4,
Column(a), SectionA. When additionalsheetsare preparedfor
SectionA, providesimilar column headingson each sheet. For
each program,functionor activity,fill in the total requirementsfor
funds(bothFederaland non-Federal)by objectclasscategories.
Line 6aj - Showthe totalsof Lines6a to 6h in each column.
Line 6j - Showthe amountof indirectcost.
Line 6k - Enterthe total of amountson Lines 6i and 6j. For all
applicationsfor new grants and continuationgrants the total
amountin column(5), Line 6k, shouldbe the same as the total
amount shown in Section A, Column (S), Line 5. For
supplementalgrantsand changesto grants,the total amount of
the increaseor decreaseas shownin Columns(1)-(4),Line 6k
shouldbe the same as the sum of the amountsin SectionA.
Columns(e) and (f) on Line5.
Line 7 - Enterthe estimatedamountof income,if any, expected
to be generatedfrom this project.Do not add or subtract this
amountfromthe total projectamount, Show underthe program

SF424A (Rev.7-97)Page3

INSTRUCTIONS
FORTHE SF424A (continued)
narrative statement the nature and source of income. The
estimatedamount of programincomemay be consideredby the
Federalgrantor agency in determiningthe total amount of the
grant.
Section C. Non-FederalResources
Lines 8-11 Enter amountsof non-Federalresourcesthat will be
used on the grant. lf in-kindcontributionsare included,providea
briefexplanationon a separatesheet.
Column (a) - Enter the program titles identical to
Column (a), Section A. A breakdownby function or
activityis not necessary.
Golumn (b) - Enterthe contributionto be made by the
applicant.
Column (c) - Enterthe amountof the State'scash and
in-kind contributionif the applicantis not a State or
State agency. Applicantswhich are a State or State
agenciesshouldleavethis columnblank.
Column (d) - Enter the amount of cash and in-kind
contributionsto be madefrom all othersources.
Golumn (e) - Entertotalsof Columns(b),(c),and (d).

Line 12 - Enterthe total for each of Columns(b)-(e).The amount
in Column(e) shouldbe equalto the amounton Line5, Column
(f), SectionA.
Section D. Forecasted Cash Needs

Line 15 - Enterthe totalsof amountson Lines13 and '14.
Section E. Budget Estimates of Federal Funds Needed for
Balanceof the Project
Lines 16-19- Enter in Column (a) the same grant program titles
shown in Column (a), Section A. A breakdownby function or
activity is not necessary.For new applicationsand continuation
grant applications,
enterin the propercolumnsamountsof Federal
fundswhichwill be neededto completethe programor projectover
the succeedingfunding periods (usually in years). This section
need not be completedfor revisions(amendments,changes, or
to fundsfor the currentyear of existinggrants.
supplements)
lf more than four linesare neededto list the programtitles, submit
additionalschedulesas necessary.
Line 20 - Enter the total for each of the Columns (b)-(e).When
additional schedules are prepared for this Section, annotate
accordinglyand showthe overalltotalson this line.
Section F. Other Budget Information
Line 21 - Use this space to explainamounts for individualdirect
object class cost categoriesthat may appear to be out of the
ordinaryor to explainthe detailsas requiredby the Federalgrantor
agency.
Line 22 - Enterthe typeof indirectrate (provisional,predetermined,
final or fixed) that will be in effect during the funding period, the
estimatedamountof the base to which the rate is applied,and the
totalindirectexpense.
Line 23 - Provideany other explanationsor comments deemed
necessary.

Line 13 - Enter the amount of cash neededby quarterfrom the
grantoragencyduringthe firstyear.
Line 14 - Enterthe amountof cash from all othersourcesneeded
by quarterduringthe first year.

3F424A (Rev.7-97)Page4

REPORT
FEDERALFINANCIAL
FederalGrantor OtherldentifyingNumberAssignedby FederalAgency
grants,useFFRAttachment)
(Toreportmultiple

1. Federal Agency and OrganizalionalElemenl
to Which Reoort is Submitted

Recipient Organization (Name and complete address including Zip code)

a. D U N SN u m b e r

RecipientAccount Number or ldentifl/ingNumber
(To reporl multiple grants, use FFR Attachment)

ProjecUGrant
Period
From: (Month,Day,Year)

Reporting Period End Date
(Month, Day, Year)

lines a-c for single or multiple grant reporting)

c. Cash on Hand (line a minus

(Use lines d-o for single grant reporting)
d

Tolal Federal funds authorized

Total Federal share (sum of lines e and
balance of Federal funds (line d minus

share to be orovided (line iminus

income exoended in accordancewith the deductionallernative
income exoended in accordance with the addition alternative

income(lineI minuslinem or line

. Remarks: Attach any explanations deemed necessary ot infotmation required by Feclenl sponsoring agency in compliance with goveming legislation:
Certification:

By signing this report, I certify that it is true, complete, and accurate to the best of my knowledge.

I am aware that

informationmav subi6ctmo to criminal.civil,or administrative
or fraudu16nt
Typed or Printed Name and Title of Authorized Certifying Official

c. Telephone (Area code, number and extension)

Signatureof AuthorizedCertifyingOfficial

e. DateReportSubmitted(Month,Day,Year)

Burden Statemanl

to the PapsMork ReductionAct, as amended.no personsar6 requiredlo respondto a collectjonof infomationunlessit displaysa validOMB ControlNumber The valid OMB control

of this @llection of

for

this

FederalFinancial Report Instructions
Report Submissions
1) Recipientswill be instructedby Federalagenciesto submit theFederal Financial Report (FFR) to
a single location, exceptwhen an automatedpaymentmanagementreportingsystemis utilized. In
this case,a secondsubmissionlocationmay be requiredby the agency.
2)

If recipientsneedmore spaceto supporttheir FFRs, or FFR Attachments,they shouldprovide
supplementalpages.Theseadditionalpagesmust indicatethe following information at the top of
eachpage:Federalgrant or other identifying number(if reportingon a singleaward),recipient
organization,Data UniversalNumberingSystem(DUNS) number,EmployerIdentificationNumber
(EIN), andperiodcoveredby the report.

Reporting Requirements
1) The submissionof interimFFRswill be on a quarterly,semi-annual,
or annualbasis,as directedby
the Federalagency.A final FFR shall be submittedat the completionof the awardagreement.The
following reportingperiodenddatesshallbe usedfor interimreports:3131,6130,9130,
or I2l3I. For
final FFRs, the reportingperiod end dateshall be the end dateof the project or grant period.
2) Quarterly and semi-annualinterim reportsshall be submittedno later than 30 daysafter the end of
eachreportingperiod. Annual reportsshall be submittedno later than 90 daysafter the end of each
reportingperiod. Final reportsshall be submittedno later than 90 daysafter the project or grant
period end date.
Note: For singleawardreporting:
1) Federalagenciesmay requirebothcashmanagement
informationon lines 10(a)through10(c)and
financialstatusinformationlines 10(d)through10(o).
2) l0(b) and 10(e)may not be the sameuntil the final report.

Line Item nstructions lbr the Federal Financia
FFR
\umber

Reporting Item

t

Instructions

Cover Information
I
FederalAgencyand
lnter the nameof the Federalagencyand organizationalelement
Jr ganizationalElementto dentifiedin the awarddocumentor as instructedby the agency.
Which Report is Submitted
FederalGrant or Other
ior a singleaward,enterthe grantnumberassignedto the awardby the
tdentifyingNumber
iederal agency. For multiple awards,reportthis information on the FFR
Assignedby Federal
\ttachment. Do not completethis box if reporting on multiple awards.
Agency
lecipient Organization
lnter the nameand completeaddressof the recipientorganization
ncludinszio code.
lnter the recipientorganization'sDataUniversalNumbering System
la
)UNS Number
'DUNS) numberor CentralContractReeistrvextendedDI-INS number.
tb
]IN
lnter the recipient organization'sEmployerIdentificationNumber (EIN).
lecipient Account Number lnter the accountnumberor any otheridenti$ing numberassignedby the
:ecipientto the award.This numberis for the recipient'suse only and is
lr Identifuing Number
rot requiredbv the Federalasencv.For multioleawards.reportthis

FFR
\umber

Reporting ltem

Instructions

informationon the FFR Attachment. Do not completethis box if
,eportingon multiple awards.
Mark appropriatebox. Do not completethis box if reporting on multiple
ReportType
twards.
Speciff whethera cashor accrualbasiswas usedfor recording
lasis of Accounting
'Cash/Accrual)
ransactionsrelatedto the award(s)and for preparingthis FFR. Accrual
rasisof accountingrefersto the accountingmethodin which expensesare
arerecorded
recordedwhenincurred.For cashbasisaccounting,expenses
paid.
whenthey are
indicatethe period establishedin the awarddocumentduring which
lroject/Grant Period,
beginsandends.
lrom: (Month, Day, Year) lederalsponsorship

J

)

\ote: Someagenciesawardmulti-yeargrantsfor a project period that is
fundedin incrementsor budgetperiods(typically annualincrements)'
Ihroughoutthe projectperiod,agenciesoften requirecumulative
reportingfor consecutivebudgetperiods.Under thesecircumstances,
mter thebeginningandendingdatesof theprojectperiodnot the budget
period.
Do not completethis line if reporting on multiple awards.
lroject/GrantPeriod,To: iee the aboveinstructionsfor "ProjecVGrantPeriod,From: (Month, Day,
'Month,Day, Year)
Year)."
Bnterthe endingdateof the reportingperiod.For quarterly,semi-annual,
End
ReportingPeriod
Date:(Month, Day, Year) md annualinterim reports,usethe following reportingperiod end dates:
or l2l3l. For f,rnalFFRs,the reportingperiodend date
3131,6130,9130,
lhall be the enddateof theprojector grantperiod.

t0

fransactions
lnter cumulativeamountsfrom dateof the inceptionof the awardthroughthe end dateof the
:eportingperiodspecifiedin line 9.
Jse Lines 10athrough10c,Lines 10dthroughl0o, or Lines 10athroughl0o, as specifiedby the
Federalagency,whenreportingon singlegrants.
UseLine12'Remarks,toprovideanyinformationdeeme
FederalCash (To report multiple grants, alsouseFFR Attachment)
Enterthe cumulativeamountof actualcashreceivedfrom the Federal
3ashReceipts
10a
lgency as of the reportingperiod end date.
lnter the cumulativeamountof Federalfund disbursements(suchas cash
lash Disbursements
t0b
arethe sum
rr checks)asof the reportingperiodenddate.Disbursements
goods
the
and
services'
for
for directcharges
tfactual cashdisbursements
rmountof indirect expenseschargedto the award and the amountof cash
ldvancesandpaymentsmadeto subrecipientsand contractors.

l0c

lash On Hand (Line 10a
vlinusLine 10b

Formultiple grants,report eachgrant separatelyon the FFR Attachment.
on the FFR Attachment
Ihe sum of the cumulativecashdisbursements
FFR.
10b,
nust equalthe amountenteredon Line
lnter the amountof Line 10aminus Line 10b.This amountrepresents
mmediatecashneeds. If more than threebusiness
lavs of cashareon hand,the Federalagencymay requirean explanation

FFR
\umber

Reporting ltem

Instructions

@

rn Line 12,Remarks,explainingwhy the drawdownwas made
oremafurelvor otherreasonsfor the excesscash.
Federal Expenditures and UnobligatedBalance: Do not completethis sectionif reportingon multiple
awards.
lnter the total Federalfundsauthorizedas of the reportingperiod end
r0d
Iotal FederalFunds
late.
Authorized
Enterthe amountof Federalfund expenditures.For reportspreparedon a
10e
iederalShareof
for direct
cashbasis,expendituresarethe sum of cashdisbursements
3xpenditures
chargesfor propertyand services;the amountof indirect expensecharged;
thevalue of third-partyin-kind contributionsapplied;and the amountof
cashadvancepaymentsandpaymentsmadeto subrecipients.For reports
preparedon an accrualbasis,expendituresare the sum of cash
disbursements
for direct chargesfor propertyand services;the amountof
indirectexpenseincurred;the value of in-kind contributionsapplied;and
thenet increaseor decrease
in the amountsowedby the recipientfor (1)
goodsandotherpropertyreceived;(2) servicesperformedby employees,
contractors,subrecipients,and otherpayees;and (3) programsfor which
no currentservicesor performanceare required.Do not include program
incomeexpendedin accordancewith the deductionalternative,rebates,
refunds,or other credits. (Programincomeexpendedin accordancewith
thedeductionalternativeshouldbe reportedseparatelv
on Line 10o.)
r0f
lederal Shareof
Jnliquidatedobligationson a cashbasisare obligationsincurred,but not
JnliquidatedObligations ret paid. On an accrualbasis,they are obligationsincurred,but for which
rn expenditurehasnot yet beenrecorded.Enter the Federalportion of
rnliquidatedobligations.Thoseobligationsincludedirectandindirect
)xpensesincurredbut not yet paid or chargedto the award,including
rmountsdue to subrecipientsand contractors.On the final report, this line
;houldbe zerounlessthe awardingagencyhasprovidedother
nstructions.
Donot includeany amountin Line l}f that hasbeenreportedin Line I0e.
Do not includeany amountin Line l0ffor afuture commitmentoffunds
'suchas a long-termcontract)for which an obligation or expensehas not
Jeenincurred.
(Sum
fotal FederalShare
3nterthe sumof Lines 10eand 10f.
log
rf Lines 10eand 10fl
3nterthe amountof Line 10dminusLine 10g.
10h
JnobligatedBalanceof
(Line
10d
iederalFunds
VlinusLine l0e)
RecinientShare: Do not completethis sectionif reportinson multipleawards.
Bnterthe total requiredrecipientsharefor reportingperiod specifiedin
10i
Iotal RecipientShare
ine 9. The requiredrecipientshareshouldincludeall matchingand cost
Required
;haringprovidedby recipientsand third-partyprovidersto meetthe level
:equiredby the Federalagency.This amountshouldnot includecost
;haringand matchamountsin excessof the amountrequiredby the
Federalagency(for example,cost oveffunsfor which the recipient incurs
rdditionalexpenses
and,therefore,contributesa gteaterlevel ofcost

@
FFR
\umber

Reporting ltem

Instructions

iharingor matchthanthe level requiredby the Federalagency).
or outlays(lessany
Enterthe recipientshareof actualcashdisbursements
l0j
lecipient Shareof
payments
to
subrecipientsand
rebates,refunds,or other credits)including
ixpenditures
:ontractors.This amountmay includethe value of allowablethird party
in-kind contributionsandrecipientshareof programincomeusedto
f-rnance
the non-Federalshareof the project or program. Note: On the
f,rnalreportthis line shouldbe equalto or greaterthan the amountof Line
l0i.
RemainingRecipientShareEnterthe amountof Line lOi minusLine 10j. If recipientsharein Line
10k
;obe Provided(Line 10i lOj is greaterthanthe requiredmatchamountin Line l0i, enterzero.
MinusLinel0i)
Prosram Income: Do not completethis sectionif reportineon multipleawards.
101
Iotal FederalProgram
Enterthe amountof Federalprogramincomeearned.Do not reportany
lncomeEarned
lrogram incomeherethat is beingallocatedas part of the recipient'scost
rharinsamountincludedin Line10i.
l0m
ProgramIncome ExpendedEnterthe amountof programincomethat was usedto reducethe Federal
in AccordanceWith the
rhareofthe totalprojectcosts.
DeductionAlternative
l0n
ProgramIncome ExpendedEnterthe amountof programincomethat was addedto funds committed
in AccordanceWith the
lo the total project costsand expendedto further eligible project or
programactivities.
Addition Alternative
10o
JnexpendedProgram
lnter the amountof Line 101minusLine lOm or Line lOn. This amount
.ncome(Line 101Minus :qualsthe programincomethat hasbeenearnedbut not expended,as of
he reportingperiodenddate.
-ine 10mor Line 10n)
ll
lndirect Expense:Completethis informationonly if requiredby the awardingagencyand in
rccordancewith agencyinstructions.
Final, or
lla
fype of Rate(s)
Jtatewhetherindirectcostrate(s)is Provisional,Predetermined,
Fixed.
Enterthe indirect costrate(s)in effect during the reportingperiod.
1lb
Rate
Enterthe beginningand endingeffectivedatesfor the rate(s).
llc
leriod From: PeriodTo
Entertheamountof thebaseagainstwhich the rate(s)wasapplied.
lld
Base
A,mountCharged
Bnterthe amountof indirectcostschargedduring the time period
11e
;pecified. (Multiply I lb. x 1ld.)
Enterthe Federalshareof the amountin 1le.
11f
FederalShare
Iotals
Enterthetotalsfor columnsI ld. 1le. and I lf.
11s
Remarks.Certification. and Asency Use Onlv
Enterany explanationsor additionalinformationrequiredby the Federal
Remarks
T2
;ponsoringagencyincludingexcesscashas statedin line 10c.
Iyped or PrintedName and lnter the nameand title of the authorizedcertifuing official.
l3a
Iitle of Authorized
lertifuine Official
lhe authorizedcerti$ringofficial must sign here.
l3b
iignature of Authorized
lertifuine Official
lnter the telephonenumber(includingareacodeand extension)of the
13c
lelephone (Area Code,
ttrumberand Extension)
ndividuallistedin Line 13a.
lnter the e-mailaddressof the individuallistedin Line 13a.
l-mail Address
l3d

FFR
\umber

l3e
14

Reporting Item

Instructions

DateReport Submitted
.Month, Day, Year)
A,sencvUse Only

Enterthe datethe FFR is submittedto the Federalagencyusing the
nonth. dav. vear format.
lhis sectionis reservedfor Federalagencyuse.

Line Item Instructions for the FederalFinancial Report Attachment
o be comoleted i

Box

Reporting Item

on cash ma

t actrvrtvtbr multr

nts.

Instructions

Number

\a

]b

+

lnter the nameof the Federalagencyand organizationalelement
FederalAgency and
CrganizationalElementto dentifredin the awarddocumentor otherwiseinstructedby the agency.
'This
informationshouldbe identicalto that enteredin Box 1. FFR.)
Which Report is Submitted
lecipient Organization
lnter the nameand completeaddressof the recipientorganization
ncludingzip code.(Sameinformationas enteredin Box 3, FFR.)
)UNS Number
lnter the recipient organization'sDataUniversalNumbering System
'DUNS) numberor CentralContractRegistryextendedDUNS number.
'Sameinformationas enteredin Box 4a. FFR.\
EmployerIdentificationNumber(EIN).
JIN
Enterthe recipientorganization's
'Sameinformationas enteredin Box 4b. FFR.)
ReportingPeriod End Date Enterthe endingdateof the reportingperiod of this report. (Same
'Month, Day, Year)
informationas enteredin Box 9. FFR.)
FederalGrant Number
Enterthe srantnumberassisnedto eachawardbv the Federalasencv.
RecipientAccountNumber Enterthe accountnumberor any other identifying numberassignedby the
:ecipientto eachaward.This numberis for the recipient'suseonly and is
rot requiredby the Federalagency.
lumulative FederalCash Enterthe cumulativeamountof the Federalshareof cashdisbursedfor
arethe sum of acfualcashdisbursements
Disbursement
:ach award.Cashdisbursements
goods
for
and
services,
the amountof indirect expenses
lor direct charges
;hargedto the award,and the amountof cashadvancesand payments
madeto subrecipientsand contractors.
Iotal
lnter the total for the CumulativeCashDisbursement.This column
ihould equalthe amountreportedon Line 10b,FFR.

FEDERALFINANCIALREPORTATTACHMENT
(Forreporting
multiplegrants)
Federal Agency and OrganizationalElement
to Which Report is Submitted (Box 'l on Page 1)

3a DUNS Number(Box4a on Page 1)

(Box3 on Page 1)
2 RecipientOrganization

ReportingPeriod End Date (Box I on Page I )
(Month,Day,Yeao

3 b E IN (B o x4 b o n P age' l)

List Informationbelow for each grant covered by this report Use additionalpages if more space is required.
ederal Grant Number

lRecipientAccount Number

lcumutative FederalCash Disbursement

AL (Should correspond to the amount on Line 10b on
OMB Appoval Nuobor 0348{061
Expir€tionDate: 10/31/20'l1
to the Papercrk Reduction Act. as amended, no peFons are required to respond to a collection of infomation unless it displays a valid OMB ContDl Number The
@ntrol number tor this infomation collection is 0348{06'l
Public reporting burden for this @llection of informalion is estimated to ave.age thirty (30) minutes per response,
time for reviewing instructions, ssarching existing data sources, galhering and mainlaining lhe data needed, and compleling and reviewing the collection of infomation
comments regarding the burden estimate or any other aspect of this collection of information, including suggeslions for reducing this burden, to the Otllce of Management

ASSURANCESAND CERTIFICATIONS
and Certifications
listedbelowif an awardis made.
Signingthe certificationon SF424 certifiesthat the Applicantwill complywith the Assurances
Certainof these Assurancesand Certificationsmay not be applicableto the Applicant.An Applicantmay not modifyany of the Assurancesand
Cetifications.
(42US C.7401etseq.);(g)protection
amended
ofunderground
sources
of
Programs
A.
Standard
Form424Bj.
Assurances
- Non-Construction
(P.1.93drinking
water
under
theSafeDrinking
Water
Actof 1974,
asamended,
I certify
Asthedulyauthorized
representative
oftheApplicant,
thattheApplicant:
ofendangered
species
undertheEndangered
Species
Act
523);and(h)protection
1. Hasthelegalauthority
to applyforFederal
assistance,
andtheinstitutional,
(P.1.93-205).
asamended,
of 1973,
(including
funds
managerial
andfinancial
capability
sufiicient
topaythenonwiththeWildandScenic
Rivers
1271etseq.)
12 Willcomply
Actof 1968(16U.S.C.
proper
planning,
Federal
management
and
shareof proiect
costs)toensure
related
to protecting
components
orpotential
mmponents
ofthenational
wildand
inthisApplication
completion
oflheproiect
described
riverssystem
scenic
2. Willgivetheawarding
agency,
theComptroller
General
of theUnited
States,
andif
inassuring
Willassisttheawarding
agency
compliance
withSection
106of the
theState,through
anyauthodzed
representative,
access
appropriate,
toandthe
(16U.S.C.470),
Actof1966,
National
Historic
Preservation
asamended
EO
papers,
rightto examine
allrecords,
books,
ordocuments
related
totheaward;
and
properties),
11593(identiflcation
andprotection
ofhistoric
andtheArchaeological
willestablish
inaccordance
withgenerally
a proper
accounting
system
accepted
Preservation
Actof 1974(16U S.C469a-1
andHistoric
etseq.)
accounling
standards
oragency
directives.
Will
comply
with
P
L
regarding
involved
in
93-348
theprotection
of human
subjecls
fromusrng
fora
3. Willestablish
safeguards
to prohibit
employees
theirpositions
research,
andrelated
development,
activities
supported
bythisawardof
purpose
thatconstitutes
or presents
theappearance
ofpersonal
ororganizational
assistance
gain.
conflict
of interest,
orpersonal
Willcomply
withtheLaboratory
Animal
Welfare
Actof 1966(P.L89-544,
as
4
Wiilinitiate
inApplication)
withintheapplicable
andcomplete
thework(activities
7 U.SC.2131et seq) pertaining
amended,
tothecare,handling,
andtreatment
of
timeframeafterreceipt
ofapproval
oftheawarding
agency
warmblooded
animals
heldforresearch,
teaching,
orother
activities
supported
by
withthelntergovernmental
5
Willcomply
Personnel
Actof 1970(42U.S.C.
4728thisaward
ofassistance
4763)relating
to prescribed
slandards
formeritsystems
forprograms
funded
Willcomply
withtheLead-Based
PaintPoisoning
Prevention
Act(42U S.C.4801
underoneof thenineteen
statutes
or regulalions
inAppendix
A of 0PM's
specifies
prohibits
painlinconstruction
etseq.)
which
theuseofleadbased
orrehabilitation
(5CFR900,Subpart
fora MeritSystem
Slandards
of Personnel
Administration
F).
ofresidence
structures.
withallFederal
relaling
Theseinclude
6. Willcomply
stalules
lo nondiscrimination
1 7 . Willcause
tobeperformed
therequired
financial
andcompliance
auditsin
(a)TitleVl
butarenotlimitedto:
RightsActof
1964(P.1.88-352)which
oftheCivil
accordance
withlheSingle
AuditActof 1984.
prohibits
(b)TitlelXof
discrimination
onthebasisof race,coloror national
origin;
1 8 . Willcomply
withallapplicable
requirements
ofallotherFederal
laws,executive
(20US C 1681-1683,
theEducation
Amendmenls
of'1972,
1685asamended
governing
'1686),
orders,
regulations
andpolicies
thisprogram
whichprohibits
discrimination
onthebasis
ofsexi(c)Section
504ofthe
(29U.S.C.794),
prohibits
Rehabilitation
Actof 1973,
asamended
which
Additional
Certifications
discrimination
(d)theAgeDiscrimination
onthebasis
ofhandicaps;
Actof 1975,
as Inaddition
provided
puEuant
andcertifications
totheassurances
bytheApplicant
to
(42U.SC.6101-6107),
prohibits
amended
which
discrimination
onthebasis
of
Form4248,theApplicanl
OMBStandard
hereby
assures
andcerlifies
that:
age;(e)theDrugAbuseOfficeandTreatment
Actot 1972(P.L.92-255),
as
1
lt isdulyorganized
andvalidly
existing
under
lhelawsofthejurisdiction
inwhich
it
(f)the
amended,
relating
tonondiscrimination
onthebasis
ofdrugabuse;
wasincorporated
orotherwise
established,
andis(orwithin30dayswillbe)
Comprehensive
Alcohol
AbuseandAlmholism
Prevention,
Treatment
and
authorized
todobusiness
inanyjurisdiction
inwhichit proposes
to underlake
Rehabilitation
Actof 1970(P.L91-616),
relating
asamended,
tonondiscrimination
inthisApplication;
activities
specified
(g)Sections
onthebasis
of alcohol
abuse
oralcoholism;
523and527ofthe
(orsimilar
governing
ItsBoard
ofDirectors
body)hasbyproper
resolution
or
PublicHealth
Service
Actof 1912 (42US C 290dd-3and290ee-3),
as
similar
action
authorized
thefiling
ofthisApplication,
including
allunderstandings
(h)
relating
amended,
to confidentiality
ofalcohol
anddrugabusepatient
records;
andassurances
herein,
mntained
anddirected
andauthorrzed
theperson
TitleVlllof theCivilRights
Actof 1968(42U.SC 360'let seq), asamended,
identified
representative
astheauthorized
of theApplicant
toactinconnection
with
relating
(i)anyother
to nondiscrimination
inthesale,rentalorfinancing
of housing;
thisApplication
andto provide
suchadditional
information
asmayberequired;
provisions
nondiscrimination
inthespecific
which
for
statute(s)
under
Application
Itwillcomply
withallapplicable
requirements
Development
oftheCommunity
Federal
is beingmade;and0 therequirements
assistance
ofanyother
Banking
andFinancial
Institutions
Actof 1994(theAct)[12U.S.C4701etseq.],
nondiscrimination
which
mayapply
statutes
totheApplication.
regulations
implementing
theActandallother
applicable
Department
ofthe
7
Willcomply,
orhasalready
mmplied,
withtherequirements
ofTitles
ll andlllofthe
procedures
(andanyregulations
Treasury
regulations
andimplementing
or
Uniform
Relocation
Assistance
Acquisition
Policies
Actof 1970
andRealProperty
procedures
which
arelaterpromulgated
tosupplemenl
orreplace
them);
(P.1.91-646)
provide
which
forfairandequitable
treatment
ofpersons
displaced
or
Itwillcomply,
withtherequirements
asapplicable
andappropriate,
of OMB
programs
whoseproperty
isacquired
asa resultof Federal
assisted
orfederally
(e.9.,
A-110andA-133)
Circulars
andanyregulations
andcirculars
which
arelater
Theserequirements
in realproperty
forproject
applytoallinterests
acquired
promulgated
tosupplement
orreplace
them,including
standards
forfundcontrol
purposes
participation
regardless
of Federal
in purchases.
andaccountability;
Willcomply
wilhtheprovisions
8
oflheHatch
Act(5U.S.C.150'l-'1508
& 7324-7328)
Ithasnotknowingly
made
andwillfully
oruseda document
containing
orwriting
principal
whichlimitthepolitical
ofemployees
whose
activities
employment
anyfalse,fictitious
orfraudulent
statement
orenfyaspartofthisApplication
or
inwholeorin oartwithFederal
activities
arefunded
funds
(TheApplicant
anyrelated
document,
conespondence
orcommunication.
andits
I
Willcomply,
asapplicable,
withtheprovisions
Act(40US C
oftheDavis-Bacon
representative
authoized
should
beaware
that,under
18U.S.C.
1001,
whoever
276alo 276a-71,
theCopeland
Act(40U.SC 276cand18 US C 874),andthe
knowingly
makes
andwillfully
or usessuchdocument
orwriting
shallbefinedor
WorkHoursandSafety
Act(40U.S.C.
regarding
Contract
Standards
327-3331,
imprisoned
fornotmorethanfiveyears,
or both);
and
laborstandards
forfederally
assisted
conskuction
subagreements.
Theinformation
inthisApplication,
andintheseassurances
andcertifications
in
purchase
if applicable,
10. Willcomply,
withfloodinsurance
requirements
ofSection
istrueandcorrect
support
oftheApplication,
tothebestoftheApplicant's
102(a)oftheFloodDisaster
Protection
Actof 1973(PL 93-234)
whichrequires
knowledge
andbelief
andthefiling
ofthisApplication
hasbeendulyauthorized.
ina special
floodhazard
intheprogram
recipients
areato participate
andto
purchase
floodinsurance
if thetotalcostof insurable
conskuction
andacquisition c. Certification
Regarding
Debarment,
Suspension,
andOtherResponsibility
is$10.000
ormore.
Matters
Covered
Transactions:
lnstructions
for Certification
- Primary
puFuant
11. Willcomply
withenvironmental
whichmaybeprescribed
standards
tothe I
primary
participant
(ihe
Bysigning
andsubmitting
thisApplication,
theprospective
qualitycontrol
(a)institutionofenvironmental
following:
measuresunderthe
Applicant)
isproviding
thecertification
setoutbelow
National
Environmental
Policy
Actof 1969(P.1.91-190)
andExecutive
Order
required
Theinability
ofa person
toprovide
theceilfication
belowwillnot
(b)notification
pursuant
(c)protection
1151a;
facilities
ofviolating
toEO1'1738;
of
inthiscovered
necessarily
resultinthedenial
of participation
transaction.
The
pursuanl
in
wetlands
to E0 11990;(d)evaluation
offloodhazards
infroodplains
provide
prospective
Applicant
shallsubmit
anexplanalion
ofwhyit cannot
the
withEO11988;(e)assurance
accordance
consistency
withtheapproved
of project
in
orexolanation
willbeconsidered
certilication
setoutbelow.Thecerlification
program
Act
Stalemanagement
developed
undertheCoastal
ZoneManagement
withtheFund's
determination
whether
lo enterintothistransaction
connection
(f)conformity
1451et
ot 1972(16U.S.C.
seq.);
ofFederal
actions
toState
(approval
oftheApplication).
However,
failure
oftheApplicant
to
andfunding
lmplementation
PlansunderSection
176(c)
of theClearAirActof '1955,
as

from
program
suchperson
oranexplanation
shalldisqualify
furnish
a certification
(b) establishing
awareness
to inform
employees
about:
a drug-free
participation
inthistransaction.
(i) thedangers
ofdrugabuse
intheworkplace;
isplaced
isa material
representation
offactuponwhichreliance
3. Thiscertification
(ii) theApplicant's
policy
workplace;
ofmaintaining
a drug-free
lf it islaterdetermined
toenterintothiskansaction.
whentheFunddetermines
(iii)anyavailable
drugcounseling,
rehabilitation,
andemployee
assistance
inaddition
to
knowingly
rendered
certification,
thattheApplicant
anerroneous
program;
this
to theFederal
Government,
theFundmayterminate
otherremedies
available
(iv) thepenalties
fordrugabuse
thatmaybeimposed
uponemployees
forcauseordefault.
transaction
violations
intheworkplace
occuning
immediate
written
notice
totheFundif atanytimelhe
4. TheApplicant
shallprovide
(c) making
inthe
it a requirement
to beengaged
thaleachemployee
leamsthatitscertification
waseroneous
whensubmitted
orhasbecome
Applicant
performance
required
oftheawardbegivena copyofthestatement
by
circumslances.
enoneous
byreason
of changed
(a);
subparagraph
'suspended,''ineligible,"
"lower
"debarred,'
lier
transactions,"
5. Theterms'covered
(a)that,
(d) notifiing
inlheslalement
required
theemployee
bysubparagraph
"person,"
"primary
transaction,"
covered
covered
transaction,"'participant,"
ofemployment
insuchgrant,theemployee
will:
asa condition
"principal,"'proposal",
and'voluntarily
excluded,"
asusedinthisclause
(i) abidebythetermsofthestatement;
and
(certification),
havethemeanings
andCoverage
sections
setoutintheDefinitions
(ii) notifytheemployer
conviction
fora
of
any
criminal
drug
usestatute
Executive
Order12549.Youmaycontact
theFundfor
oftherulesimplementing
violation
intheworkplace
nolaterthanfivecalendar
occuning
days
(31CFRpart19)
inobtaining
a copyofthose
regulations
assistance
aftersuchconviction;
proposed
that,should
the
6. TheApplicant
agrees
bysubmitting
thisApplication
(e) notifying
thegranting
agency
inwriting,
within
tencalendar
daysafier
into,it shallnotknowingly
enterintoanylowertier
covered
transaction
beentered
(d)(ii)froman
receiving
notice
ofa conviction
undersubparagraph
ineligible,
transaction
witha person
whoisdebarred,
suspended,
declared
covered
receiving
employee
orotherwise
actualnotice
of suchconviction;
fromparticipation
inthiscovered
unless
or voluntarily
excluded
transaction,
(0
following
within
noticeunder
taking
one
of
the
actions,
30
days
of receiving
Fund
authorized
bythe
(d)(ii),
withrespect
whoissoconvicted:
subparagraph
toanyemployee
7. TheApplicant
thisApplication
thatit willinclude
the
further
agrees
bysubmitting
(i) taking
personnel
appropriate
action
against
suchanemployee,
upto
Ineligibility
Regarding
Debarment,
Suspension,
and
clause
titled'Certification
withtherequirements
ofthe
andincluding
termination,
consistent
Transaction,'to
Voluntary
Exclusion-Lower
TierCovered
beprovided
bytheFund,
Rehabilitation
Actof 1973,asamended;
or
for
without
modification,
inalllowertiercovered
transactions
andinallsolicitations
(ii) requiring
suchemployee
ina drugabuse
to participate
satisfactorily
(see31CFRpart19,Appendix
B)
lowertiercovered
transactions
program
forsuchpurposes
bya
assistance
orrehabilitation
approved
ina covered
transaction
mayrelyupona certification
ofa prospective
8. A participant
Federal,
State,
or localhealth,
lawenforcement,
orotherappropriate
participanl
ina lower
transaction
thatit isnotdebarred,
suspended,
tiercovered
agency;
ano
fromthecovered
unless
il knows
that
ineligible,
orvoluntarily
excluded
transaction,
(S) making
a drug-free
workplace
a goodfaithefforttocontinue
to maintain
iserroneous.
A participant
maydecide
themethod
andfrequency
thecertification
(a),(b),(c),(d) (e)and(f).
implementation
ofsubparagraphs
through
may,butis
bywhichit determines
theeligibility
ofitsprincipals
Eachparticipant
provided
inthespace
2. TheApplicant
mayinsert
below
thesite(s)
forthe
notreouired
theNonorocuremeni
Lisl.
to.check
performance
ofwork(activities
carried
outbytheApplicant)
to bedonein
intheforegoing
establishment
ofa
9. Nothing
contained
shallbeconstrued
torequire
(Street
withtheaward(Place
of Performance
Address,
connection
City,County,
inorderto render
ingoodfaiththecertification
required
system
of records
bythis
StateandzipCode)):
isnotrequired
andinformation
ofa participant
toexceed
clause.Theknowledge
NotApplicable
possessed
person
intheordinary
course
of
thatwhichis normally
bya prudent
business
dealings.
F. Certification
Regarding
Lobbying
10 Except
fortransactions
if a
authorized
underpanagraph
6 oftheseinstructions,
1. TheApplicant
cerlifies,
tothebestof itsknowledge
andbelief,
that:
participant
in a covered
transaction
knowingly
entersintoa lowertiercovered
person
is
ineligible,
voluntarily
witha
who suspended,
debaned,
or
transaction
(a) NoFederal
fundshavebeenpaidorwillbepaid,byoron
appropriated
inthistransaction,
inaddition
excluded
fromparticipation
tootherremedies
forinfluencing
oratlempting
behalf
oftheApplicant,
toanyperson
to
theFundmavterminate
thistransaction
for
available
totheFederal
Government.
influence
anofficer
a Member
ofCongress,
an
oremployee
ofanyagency,
causeor default.
officer
oremployee
ofCongress,
oranemployee
ofa Member
ofCongress
inconnection
withtheawarding
ofanyFederal
contract,
themaking
ofany
D. Certification
Regarding
Debarment,
Suspension,
andOtherResponsibility
grant,
loan,
intoofany
Federal
themaking
ofanyFederal
theentering
Matters- PrimaryCovered
Transactions
renewal,
cooperative
agreement,
andtheextension,
continuation,
primary
participant
(theApplicant)
1
Theprospective
certifies
tothebestofits
grant,loan,or
or modification
ofanyFederal
contract,
amendmenl,
knowledge
andbelietthatit anditsprincipals:
cooperative
agreement;
proposed
(a) arenotpresently
fordebarment,
declared
debarred,
suspended,
(b) lf anyfundsotherthanFederal
fundshavebeenpaidorwillbe
appropriated
ineligible,
fromcovered
transactions
byanyFederal
orvoluntarily
excluded
paidtoanyperson
or
forinfluencing
orattempting
to inffuence
anofficer
oragency;
department
anofficer
oremployee
of
employee
ofanyagency,
a Member
ofCongress,
periodpreceding
(b) havenotwithina three-year
thisApplication
been
in mnnection
of Congress
withthis
Congress,
oranemployee
ofa Member
rendered
against
themforcommission
of
convicted
ofor hada civiljudgment
FormLLL,
Standard
Application,
theundersigned
shallcomplete
andsubmit
inconnection
withobtaining,
toobtain,
fraudora criminal
offense
attempting
'Disclosure
' inaccordance
Formto Report
Lobbying,
withitsinskuctions;
a public(Federal,
Stateorlocal)transaction
orcontract
under
or performing
an0
violation
statutes
or
a publictransaction;
of Federal
orStateantitrust
(c) TheApplicant
shallrequire
thatthelanguage
ofthiscertification
beincluded
bribery,
falsification
or
commission
of embezlement,
theft,forgery,
intheaward
documents
forallsubawards
ofalltiers(including
subcontracts,
property;
falsestatements,
stolen
destruction
of records,
making
or receiving
andcontracls
undergrants,
loans,
andcooperative
agreements)
subgrants,
(c) arenotpresently
fororotherwise
orcivilly
charged
bya
indicted
criminally
andthatallsubrecipients
shallcertify
anddisclose
accordingly.
governmental
entity(Federal,
ofanyofthe 2. Thiscertification
Stateorlocal)withcommission
isplaced
isa material
representation
offactuponwhichreliance
(1)(b)ofthiscertification;
inparagraph
and
offenses
enumerated
isa
ismadeorentered
into.Submission
ofthiscertification
whenthistransaction
period
preceding
(d) Havenotwithina three-year
hadoneor
thisApplication
prerequisite
intothistransaction
imposed
bysection
1352,
formaking
orentering
(Federal,
forcause
or
morepublictransactions
Stateor local)terminated
whofailstofiletherequired
certification
shallbe
title31,U.S.Code.Anyperson
default.
for
of notlessthan$10,000
andnotmorethan$100,000
subject
toa civilpenalty
in thiscertification, eachsuchfailure
WheretheApplicant
isunable
to certiry
toanyofthestatements
tolhisproposal.
suchApplicant
shallattach
anexplanation
E.
1

Regarding
Drug-FreeWorkplaceRequirements
Certification
workplace
by:
TheApplicant
certifies
thatit willprovide
a drug-free
(a) publishing
manufacture,
a statement
notifying
employees
thattheunlaviful
possession,
substance
is
distribution,
dispensing,
oruseofaconholled
prohibited
thatwillbe
intheApplicant's
workplace
andspecifying
theactions
employee
forviolations
ofsuchprohibitior.,
takenagainst

DISCLOSURE
OF LOBBYINGACTIVITIES

Approvedby OMB

0348-0046
Completethis form to discloselobbyingactivitiespursuantto 31 U.S.C.1352
reversefor publicburdendisclosure.
3. Report Type:
2. Statusof FederalAction:
1. Type of FederalAction:
bid/offer/application
f__l a, contract
f-l a. initialfiling
[-la.
!b.
grant
initialaward
b. materialchange
b.
"
post-award
For
c.
MaterialChangeOnly:
agreement
c. cooperative
year
quarter
d. loan
date of last report
e. loanguarantee
f. loan insurance
5. lf ReportingEntity in No. 4 is a Subawardee,Enter Name
4. Name and Address of ReportingEntity:
subawardee
and Addressof Prime:
erime
!
!
if known:
Tier _,

ConqressionalDistrict, if known'.4c
6. Federal Department/Agency:

CongressionalDistrict,if known:
7. FederalProgramName/Description:

CFDANumber,if applicable:
8. FederalAction Number,if known:

9. Award Amount, if known:
$

10. a. Name and Address of Lobbying Registrant
(if individua[ last name, first name, Ml):

b. Individuals PerformingServices (includingaddressif
differentfrom No. 10a)
(last name, firstname,Ml):

,l,l
' "

Signature:

Informationrequestedthrough this form ls authorizedby tille 31 U.S.C. section
1352. This disclosurs of lobbying activitiesis a matorial ropresontationof fact
upon which r6lian@was placed by the tier abovewhen this transactlonwas made
or entered into This di$losure is required puGuant to 31 U S C 1352 This
infomation will b€ availablofor publicinspection Any p6Eon who failsto file the
requireddisclosuE shallbesubjecttoa civilpenaltyofnollessthan $10,000and
not more than $100.000 for each such failure

PrintName:
Title:
TelephoneNo.:

Date:
Authorizedfor LocalReoroduction
StandardFormLLL (Rev.7-97)

INSTRUCTIONS
FORCOMPLETION
OF SF.LLL,DISCLOSURE
OF LOBBYINGACTIVITIES
This disclosureform shall be completedby the reportingentity,whethersubawardee
or primeFederalrecipient,
at the initiation
or receiptof a coveredFederal
pursuantto title31 U.S.C.section1352.Thefilingof a formis requiredfor eachpaymentoragreementtomake
action,or a materialchange
to a previousfiling,
paymenttoany lobbyingentityfor influencing
or attempting
to influencean officeror employeeofanyagency,a Memberof Congress,an officeror employeeof
Congress,or an employeeofa MemberofCongressin connectionwith
a coveredFederalaction.
itemsthatapplyforboththe initialfilingand material
Completeall
guidancepublishedby the Officeof Management
changereport.Referto the implementing
and Budgetfor additional
information.

1. ldentifythe typeof coveredFederalactionfor whichlobbyingactivityis and/orhas beensecuredto influencethe outcomeof a coveredFederalaction.
2. ldentifythe statusofthe coveredFederalaction.

3' ldentifytheappropriateclassificationof
thisreport.lf thisisafollowupreportcausedbyamaterialchangetotheinformationpreviouslyreported,ente
the yearandquarterinwhichthe changeoccurred.
Enterthe dateof the lastpreviouslysubmitted
reportbythis reportingentityforthis coveredFederal
action.
4. Enterthe full name,address,city,Stateandzip codeof thereporting
entity.IncludeCongressional
Distrrct,
if known.Checkthe appropriateclassification
of the reporting
entitythatdesignates
if it is, or expectsto be,a primeor subaward
recipient.
ldentifythetierof the subawardee,e.g.,
the first subawardee
of the primeis the 1st tier.Subawardsincludebutare not limitedto subcontracts,
subgrantsand contractawardsundergrants.
5. lf the organizationfiling
the reportin item4 checks"Subawardee,"then
enterthe full name,address,city,Stateand zip code of the primeFederal
recipient.IncludeCongressional
District,if known.
6. Enterthe nameof the Federalagencymakingthe awardor loancommitment.
Includeat leastoneorganizationallevel
belowagencyname,if known For
example,Departmentof Transportation,
UnitedStatesCoastGuard.
7. Enterthe Federalprogramnameor description
for the coveredFederalaction(item1). lf known,enterthe full Catalogof FederalDomesticAssistance
(CFDA)numberfor grants,cooperative
agreements,
loans,and loancommitments.
8- Enterthe most appropriate
Federalidentirying
numberavailableforthe Federalactionidentified
in item 1 (e.g.,Requestfor Proposal(RFp) number;
Invitationfor
Bid (lFB) number;grantannouncementnumber;
grant,or loanawardnumber;the application/proposal
the contract,
controlnumber
assignedby the Federalagency).Includeprefixes,e.g , "RFP-DE-90-001."
9. For a coveredFederalactionwheretherehas beenan awardor loancommitment
by the Federalagency,enterthe Federalamountof the awardiloan
commitmentfor the primeentityidentifiedin item4 or 5.
10. (a) Enterthe full name,address,city,Stateand zip codeof the lobbyingregistrant
underthe LobbyingDisclosure
Act of 1995 engagedby the reporting
entityidentifiedin item4 to influencethe coveredFederalaction.
(b) Enterthe full namesof the individual(s)
performing
services,and includefull addressif differentfrom 10 (a).EnterLastName,FirstName,and
MiddleInitial(Ml).
11. The certifyingofficialshallsignand datethe form,printhis/hername,title,and telephonenumber
to the Paperuvork
Reduction
Act, as amended,no personsarerequiredto respondto a collection
of information
unlessit displaysa validOMB
. The validOMB controlnumberfor this information
collectionis OMB No. 0348-0046.Publicreportingburdenfor this collectionof information
is
to average10 minutesper response,includingtimefor reviewing
instructions,
searchingexistingdata sources,gatheringand maintaining
the
, and completingand reviewingthe collectionof information.Sendcommentsregarding
the burdenestimateor any otheraspectof this collection
includingsuggestions
for reducingthis burden,to the Officeof Managementand
Budget,Paperwork
ReductionProject(0348-0046),
Washington,
20503

Low IncomeTaxpayerClinics(LlTCs)
ApplicationInformation
or !
Type of Grant (Checkone) ! rsr! Controversy
one)
Grant Period Request (Check
! SingteYearrequest(Newandreturningctinics)
grant)
request(Currentty
in or applyingfor a multi-year
[
! Mutti-year

Both

1stof3 years

!

2nd of3 years

!

3rd of3 years

Name
Gontact lnformation

Phonenumber

E-mailaddress

Street Address

MailingAddress

ZIP + 4 code

City

Nameof Clinic
ClinicMailingAddress

Clinic Street Address

ZIP + 4 code
Publictelephonenumber

Toll-Freetelephonenumber(if applicable)

Languagesservedin additionto English

LITC lnternet(Web) address(if applicable)

Cfinic Director fnformation (ClinicDirectorinformationwill not be includedin Publication4134)

E-mailaddress

Phonenumber
Qualified Tax Expert

lnformation

Phonenumber

E-mailaddress

Phonenumber

E-mailaddress

Street Address

Mailing Address

ZIP + 4 code
Number
36126D
ror 13424 (Rev.5-2010) Catalos

www.rrs.gov

RevenueService
Department
of the Treasury-lnternal

LITGTax InformationAuthorization
As providedfor in Publication3319,all applicantsfor an LITC grantmust be in
compliancewith Federaltax responsibrTifies.
The LITC ProgramOfficewill conduct
compliancechecks on organizationsapplyingfor an LITC grant and will alsoconduct
periodicchecksthroughoutthe grantperiod. Therefore,any LITC that is paft of a larger
organization(e.9., university)will need to have an authorizedofficialfrom the larger
organization complete the following authorization:
Nameof Academiclnstitutionor otherParentOrganization:

Nameof Low IncomeTaxpayerClinic:

I authorizethe InternalRevenueServiceto disclosethe followingreturninformation,
as
that term is definedin InternalRevenueCodesection6103(b),of the Academic
(listedabove)to the Directorof the Low Income
Institutionor ParentOrganization
TaxpayerClinic(listedabove)in connection
withthe clinic'sapplication
for a low income
taxpayerclinicmatchinggrantandcontinued
to suchgrant.Specifically,
entitlement
I
authorizethe InternalRevenueServiceto disclosethatthe Academiclnstitution
or
ParentOrganization
has an outstanding
federaltax liability(amount,type of tax, and
periods)that may affectthe approvalof the clinic'sgrantapplication
by the Internal
RevenueServiceor the clinic'scontinuedentitlement
to suchgrant.
I am awarethat withoutthisauthorization
the returninformation
of the Academic
Institutionor ParentOrganization
is confidential
and is protectedby law underthe
InternalRevenueCode. I certifythat I am authorizedby lawto bindthe Academic
Institutionor ParentOrganization
and that I haveauthorityto executethis consentto
disclosereturninformation.
TaxpayerName:
TaxpayerAddress:
Number:
Employerldentification
Nameand Titleof AuthorizedPerson:
Signatureof AuthorizedPerson:
TelephoneNumberof AuthoriredPerson:
Date:

GRANTAGREEMENT
The GrantAgreementis enteredinto by the InternalRevenueService,Departmentof the Treasury,UnitedStatesof
America,hereinafterreferredto as the lRS. and
GontractNumber
hereinafter
referredto as the recipient.
The recipientagreesto operatean LITCProgramin conformitywith the approvedGrantApplication,which is
governedby:
1. 26 U. S .C g
. 7 5 2 6 ;a n d

The Maximumamountavailablefromthe IRSunderthisGrantAgreement
is $
increasedin writingonly by the lRS, TaxpayerAdvocabService,LITCprograt
1111Cons ti tu ti o n A v N
e .,W ,R o o m1 0 3 4 ,Washi ngton,
D C 20n4.
lmplementationof the Trafficking Victims ProtectionAct of 2000,

(2007)
c.F.R.S 17s.15

@

1. Youastherecipient
youremployees,
subrecipients

of timethat the awardis in effect:

ii.)Procurea commercial
sexactduringI

ii. )H a sa n
violateda

the awardis in effect;or
subawards
underthe award.

2. fhe lRS, as the Federalawarding
subrecipientthat is a privateentity
i) ls determinedto

U.S.C.S 7104)- See 2
' employeesmay not-

i.) Engagein severeformsof traffickingin

iii.)Useforcedlaborin the

is amountmay be

terminatethisaward,withoutpenalty,if you or a
in paragraphs
(1Xi)- (iii)aboveof thisawardterm;or
by the IRSofficialauthorizedto terminatethe awardto have
(1Xi)-(iii)of thisawardtermthroughconductthat is eitherunderthisaward:or

or the subrecipient
usingthe standards
anddue processfor imputingthe conduct

for the IRS
Signature

Date

Form12183(Rev.2/2008)
CatalogNo.26967 www.irs.govDepartment
of theTreasuryInternalRevenueService

ir(J

This pageintentionallyleft blank.

LITC ProgramGrantApplicationPackageSubmissionChecklist

SingleYearGrantApplications
(Newand ReturningClinics)
for an LITCProgramGrantmustincludethe followinginformation:
Singleyearapplications
Background Information (limited to 15 pages,double-spaced)
ItemsdescribedunderSectionVl of thispackage.
Determinationof Program Performance
ItemsdescribedunderSectionVl of thispackage.
BudgeUFinancialInformation
ItemsdescribedunderSectionVl of thispackage.
Requisitesfor PackageSubmission
(foursets).Double-space
witha blue ink pen (application,
and signall documents
in quadruplicate
Submitapplication
ceftifications,efc). Each set of documentsmusthaveoriginalsignatures.
PackageAssembly
It is very importantthat the LITC ProgramGrantApplicationPackagebe assembledcorrectly.A copy of the standard
packagemustbe assembledin the
The application
are includedin AppendixA of thispublication.
formsand certifications
followingmanner:
tr

Sheet.
1. CompletedForm 13424,IRSLow IncomeTaxpayerClinic(LITC)ProgramGrantApplication

tr

2. StandardForm 424,Applicationfor FederalAssistance

n

3. BackgroundInformation

!

organization
as exemptunderIRCSection501(c)
letterissuedby IRS recognizing
4. Copyof determination
(if applicable)

n

or otherinstitution
of higherlearning
for college,university
5. Copyof letterof academicaccreditation
(if applicable)

I

6. Determinationof ProgramPerformance(one for each qualifyingprogram,if applicable)

n

lnformation(onefor eachqualifyingprogram,if applicable)
7. BudgeVFinancial

n

8. CivilRightsStatementas describedin SectionlV, D of thispackage.

n

9. StandardForm LLL, Disclosureof LobbyingActivities,signedby an authorizedrepresentative
of the organization.

n

of the organization.
10. Tax lnformationAuthorization(if applicable)signedby an authorizedrepresentative

rorn13424-D(+-zoto)

CatalogNumber54950J

www.rrs.gov

of the TreasuryJnternalRevenueService
Department

Ghecklist
LITCProgramGrantApplicationPackage
Submission
GontinuingMulti-YearGrantApplications
Continuingmulti-yearapplicationsfor an LITCProgramGrantmustincludethe followinginformation:
ContinuationRequest
LetterdescribedunderSectionVl of thispackage.
BudgeUFinancial Information
ItemsdescribedunderSectionVl of thispackage.
Requisitesfor PackageSubmission
and sign all documentswith a blue ink pen (application,
Submitapplicationin quadruplicate(foursets).Double-space
certifications,
etc). Eachset of documentsmusthaveoriginalsignatures.
PackageAssembly
It is very importantthat the LITC ProgramGrantApplicationPackagebe assembledcorrectly.A copy of the
packagemustbe
Theapplication
standardformsand certifications
are includedin AppendixA of thispublication.
assembledin the followingmanner:

n
n
n

1. CompletedForm 13424,IRSLow IncomeTaxpayerClinic(LITC)ProgramGrantApplication
Sheet.
2. StandardForm424,Application
for FederalAssistance
3. Letterrequesting
continuation
in the LITCProgramfor the 2011grantcycle.

tr

- Non-Construction
Programs(onefor eachqualifying
4. StandardForm 4244, BudgetInformation
program (controversyand ESL),if applicable).

n
n
n
n
n
n

and ESL),if applicable).
5. BudgetNarrative(onefor each qualifyingprogram(controversy
6. Detaileddescriptionof the sourceof matchingfunds.
7. Estimateof fundsthatwill not be expendedduringthe 2010year.
8. CivilRightsStatementas describedin SectionlV, D of thispackage.
9. StandardForm LLL, Disclosureof LobbyingActivities,signedby an authorizedrepresentative
of the organization.
of the
10. Tax fnformationAuthorization(if applicable)signedby an authorizedrepresentative
organization.

rorn13424-E(a-zoro)

CatalogNumber54951U

www.rrs.gov

RevenueService
Department
of the Treasury-lnternal

LITCProgramlnterimReportPackageSubmissionChecklist
Pleaseincludethischecklistas the coversheetfor yourlnterimReportPackage.
n 1. A completedForm 425,FederalFinancialReportand Form425a, FederalFinancialReportAttachment(if
for the periodJanuary1 throughJune30.
necessary)
ZZ. n completefinancialnarrative,describinghow grantfundswere expendedfor the periodJanuary1
throughJune30.
n a. lf you are fundedfor bothcontroversyand ESL,each programneedsa separatefinancialnarrative.
n b. Includea statementof unusedfunds
FundingRequest.lf yourorganization
wouldliketo requestadditional
n c. lf Applicable- An Additional
fundingand explainhowthe fundswill be spent.
funding,includea separateletterrequesting
additional
The grantawardand amountof additional
fundsbeingrequested
cannotexceed$100,000.
I3.

ProgramNarrativemustincludethe following:
program
I a. Detailedstrategyusedfor monitoring/evaluating
n b. Descriptionof how programsuccessis definedand measured
the program
E c. Explanationof the progressmadein implementing
f] d. Statusof proposedgoalsand objectives
goalsand objectives
of impediments
to meetingestablished
n e. Description
!

f. Descriptionof the clinic'seffortsto publicizethe program

or otherassistanceand nameof workshops
E g. Descriptionof the type of representation
n h. Descriptionof any additionalactivitiesnot describedpreviously
n

i. Descriptionof any Interestinglssueor SuccessStory(be carefulnot to includetaxpayeridentifyinginformation)

n j. Statementdescribingthe reasona controversycasewas acceptedwherethe amountin controversy
exceeded$50,000
E 4. lnterimand Year-EndReportForm(Form 13424-Ain AppendixC
Name of personthat completedForm 13424-A
Phonenumber

Es . SupplementallssuesForm (Form 13424-8in AppendixC (controversyonly))
Name of personthat completedForm 13424-8

Phonenumber

! 6. AdvocacyReportForm(Form 13424-Cin AppendixC)

rorn13424-Gt+-zotot

CatalogNumber55036G

www.rrs.gov

Departmentof the Treasury-lnternalRevenue Service

ReportPackage
Ghecklist
LITCProgramYear-End
Submission
Pleaseincludethis checklistas the coversheetfor yourYear-EndReportPackage.
E t. n completedForm 425,FederalFinancialReportand Form425a,FederalFinancialReportAttachment(if
necessary)
for the periodJanuary1 throughDecember31.
howgrantfundswereexpendedfor the periodJanuary1
describing
I Z. n completefinancialnarrative,
throughDecember31.
of the actualcostsfor all expenses.
and explanation
n a. ltemization
and amountof matchingfundsreceivedfor the LITCprogram.
n O. tne source,date,availability
for ESLand Controversy.
E c. Separatefinancialnarratives
funds.
n d. Statementof amountof unobligated
! 3. ProgramNarrativefor the periodJanuary1 throughDecember31:
of the LITCProgram
E a. lmplementation
E b. Informationprovidedto ESL taxpayers
volunteers,
and LITCemployees
E c. Trainingprovidedto students,
E d. Casetracking
! e. Publicityfor the LITC
n f. ReferralMechanismfor Controversies
tr g. Privacyand confidentiality
n n. Pro Bonopanel
I

i. Nominalfees (if any)

!

i. oetiveryof services

E k. Miscellaneous
n

l. Programgoals

Activities(includeInteresting
lssuesor SuccessStoriesbut be carefulnotto includetaxpayer
E m. Additional
identifying
information)
n n. LastYearin LITCProgram(if applicable)
I

o. Specialordersfor studentpractice

n p. Statementdescribingthe reasona controversycasewas acceptedwherethe amountin controversy
exceeded$50.000

n + .lnterimand Year-EndReportForm(Form13424-Ain

Ll c.

xc)

Name of personthat completedForm 13424-A

Phonenumber

fssuesForm(Form 13424-8in
Name of personthat completedForm 13424-B

only))
Phonenumber

n 6. AdvocacyReportForm (Form 13424-Cin AppendixC)

rorm13424-H(+-zoto)

CatalogNumber55037R

www.rrs.gov

Department of the Treasury-lnternal Revenue Service

AppendixC
Interimand Year-End
ReportForm
and Instructions
lssuesForm
Supplemental
and Instructions
AdvocacyInformation
Form
and
VofunteerlPro BonoTime Reporting
Form(optionaluse)

This pageintentionallyleft blank.

Low Income TaxpayerClinics (LlTCs)2011Interimand Year-EndReport
Nameof Clinic
1 through
June30,2011 or I
Reporting Period f] tnterimReport- January
Report
Report Type
! OriginatReport or ! Amended
Glinic Type

flesl crinic

!

I sotn

Controversy
Clinic

Does the organizationhave a pro bono panel
Doesthe organizationprovideCLE or CPEtax law training
Doesthe

Year-EndReport- January't throughDecember31,2011

lves

n ruo

lves n No
Yes nruo

havea U.S.Tax Court

Part l. ESL Activities
Enterthe numberof outreachactivitiesconductedduringthe reportingperiod.
a. Enterthe numberof ESL taxpayerswho attendedoutreachactivities
duringthe reportingperiod.
Enterthe numberof Educational
Workshopsconductedduringthe
reportingperiod.
a. Enterthe numberof ESL taxpayerswho attendedEducational
Workshops
duringthe reportingperiod.
Enterthe numberof CLE or CPE Sessionsheldto recruitpro bonopanel
members.
Enterthe numberof directcontactsor one-on-oneconsultations
with ESL
taxpayersduringthe reportingperiod.
Enterthe numberof radioor televisionadvertisements
/ appearances
and
newspaperarticlesduringthe reportingperiod.
Enterthe numberof ESL taxpayersreferredfor controversy
representation
during
the reportingperiod.

Return and Other Tax Form PreparationActivities
Enterthe numberof returnsthatwereancillary
to ESLoutreachandeducational
activities.(lf providingESL and controversyservicesand the preparation
of a
returnis directlyrelatedto a controversy,
do not countany such returnhere.
See Part ll, Line 11)
Enterthe numberof Individual
Taxpayerldentification
Number(lTlN)applications
preparedduringthe reportingperiod thatwere ancillaryto ESLoutreachand
educationalactivities.(lf providingESL and controversy
servicesand the
preparationof an lTlN applicationis directlyrelatedto a controversy,
do not count
any suchreturnhere.See Partll, Line12)

-I$[B
.v

lf your clinic is ESL only, DO NOT complete any other portion of this form for the reporting period.

Part ll. Controversy Activities
Enterthe numberof casesthat wereworkedin the previousyearthat remained
openas of J an u a ry1 ,2 0 1 1 .
Enterthe numberof new casesopenedduringthe reportingperiod.
o For the Year-EndReport, enterthe total numberof new casesopened
fromJanuary1,2011throughDecember
31,2011.
ror^ 13424-A

CatalogNumber53040U
1R"u.5-2O1O)

www.rrs.gov

Departmentof the Treasury-lnternalRevenue Service

Nam e o f C l i n i c

Part ff. Controversy Activitles @ontinued)
Total numberofopen cases.
o For the lnterimReoortadd lines1i and2i.
a Forthe Year-End
add linesliand2ii

a. Enterthe numberof caseswherethe taxpayer'sincomeexceeded250%
of the povertylevelduringthe reportingperiod.
b. Enterthe numberof ALL issuesaddressedduringthe reportingperiod.This
lssues
lineshouldequalline 36 on Form13424-8,Supplemental
c. Enterthe numberof caseswherea petitionwas filedin the U.S.Tax Court.
d. Enterthe numberof refundsuitsfiled in a U.S.DistrictCourtor the U.S.Court
of FederalClaims.
e. Enterthe numberof caseswherethe clinicis workinga bankruptcyissuewith
a tax issue.
f. Enterthe numberof controversycasesopenedfor ESLtaxpayers.
g. Enterthe numberof caseswherethe clinicenteredintoa representation
agreementand referredthe caseto a qualifiedpro bonorepresentative.
h. Enterthe numberof casesreferredto TAS.
period.
Enterthe numberof casesclosedduringthe reporting
Enterthe numberof consultations
duringthe reportingperiodthat did not resultin
reoresentation.
in the U.S.Tax Courtduringthe
Enterthe numberof informalconsultations
reportingperiod.
in a U.S.DistrictCourtor the
Enterthe numberof informalconsultations
U.S. Courtof FederalClaimsduringthe reportingperiod.
that did not qualify for clinicservicesbut were
Enterthe numberof consultations
referredto appropriatealternativessuchas statebarsduringthe reportingperiod.
Enterthe numberof statetax mattershandledduringthe reportingperiodthat
were relatedto a controversycase.
Enterthe numberof taxpayersassistedduringthe reportingperiod,including
those for whom caseswere not opened.
a. Enterthe numberof taxpayerswho attendeda workshopand as a result
becamea controversyclient.

Returnand Other Tax Form PreparationActivities
Enterthe numberof tax returns(includingamendedreturns)thatwere prepared
by the clinicduringthe reportingperiod that weredirectlyrelatedto a controversy.
of a returnis
(lf providingESL and controversyservicesand the preparation
ancillaryto ESL outreachand educationalactivities,do not countany suchreturn
here.See PartI, Line7).
preparedduringthe reportingperiodthat
Enterthe numberof lTlN applications
were directly relatedto a controversy.

Publicity and Outreach Activities
Enterthe numberof outreachesconductedduringthe reportingperiod.
Enterthe numberof CPE or CLE Sessionsheldto recruitpro bono panel
members.
/ appearances
and
Enterthe numberof radioor televisionadvertisements
newspaperarticlesduringthe reportingperiod.
porn13424-A

53o4ou
Number
1R"u.5-2010)Catalog

www.rrs.gov

RevenueService
of the Treasury-lnternal
Department

Instructionsfor the 2011 Low lncome TaxpayerClinics lnterim and Year-EndReport Form
Note. When submittingyour Interim or Year-End Reports
package,this form is part of the ProgramNarrative.
Under unusual circumstances,clinics may request an
extensionof time to submitthe InterimReportpackageor the
Year-EndReportpackage.Requestsfor an extensionmustbe
submitted in writing with a detailed explanation.Requests
shouldbe sent by e-mailto the clinic'sassignedanalystin the
LITC ProgramOfficepriorto the due date of the report.Once
received,the analystwill ask the Directorof the Low Income
Taxpayer Clinic Program to review it and make a
determination.lf the report is received by the approved
extensiondate,it willbe considered
timely.
Note. Failure to timely submit requiredreportsto the LITC
Program Office may result in freezingof funds, reductionof
futurefunds,or terminationof the grant.

Line 1. Reporton this line the numberof outreachactivities
that may include communityevents such as fairs, forums,
meetings,etc. to informthe publicaboutclinicservices.Clinic
service informationat these events can include, but is not
limitedto, publicspeaking,distributionof marketingmaterials,
and face-to-face
conversation.
Line 1a. Reporton this line the numberof ESL taxpayerswho
attendedoutreachactivities.
Line 2. Educational
workshopsare conductedin a class-type
or lecture setting. Examples could be community college
classes,sessionsat local communitycenters,or sessionsat
churches.Workshopscan cover informationsuch as: how to
completea Form W-4 for withholding,filing requirements,
collectionor examinationissues.or how to locatetrustworthv
tax professionals.

Purpose

Line 2a. Reporton this linethe numberof ESLtaxpayerswho
attendededucational
workshops.

This form is designed to capture the work the clinic has
performedduring the reportingperiods.This form must be
completedby both ESL and Controversyclinics. The LITC
programrequiresclinicsto submittwo reportsduringa grant
cycle - an Interimreportand a Year-Endreport.Thesereports
are used by the ProgramOffice to determinethe effectiveness
of LITC operations by reviewingservices providedto low
incometaxpayersand ESL taxpayers.

Line 3. Reporton this line the numberof CPE or CLE
sessionsheldto recruitpro bonopanelmembers.

Note. Interimand Year-EndReports(includingthis reportform
contained)may be releasedunderthe Freedomof Information
Act (FOIA). ln responseto a FOIA request,the LITC Program
Officewill releasethese reportsafterappropriateredactionsto
ensureconfidentiality
of taxpayerinformation.

Line 5. List only the number of events, articles and
advertisements
on this line. Use the Program Narrativeto
provideadditionalinformation
such as, the numberof potential
listeners,viewersand readers,as well as the frequencyof the
programs,articles,and any other information
advertisements,
aboutyourpublicityefforts.

Reporting Requirements
ESL Glinics. lf your clinic has been funded for ESL activity
only,completePart I of the form.
Gontroversy Glinics. lf your clinic has been funded for
controversyactivityonly,completePart ll of the form.
Both ESL and Gontroversy.lf your clinichas beenfundedfor
both ESL and controversyactivities,completeboth Part I and
Part ll of the form
Reporting period. Check all boxes that apply. LITCs are
required to report on clinic activitiestwice during the grant
cycle. The grant cycle is January1 throughDecember31 for
the year in which a grantaward is received.An InterimReport
is requiredfor the period January 1, 2011 throughJune 30,
2011; the Year-End Report is required for the period of
January1 throughDecember31,2011.
Specific Instructions

Line 4. Reoorton this line the numberof directcontactsand
one-on-oneconsultations.
These typicallyfollow an outreach
event or educationalworkshop about taxpayer rights and
responsibilities.
Directcontactsor consultations
are wherethe
clinicprovidesspecificinformation
on the attendee'sissue.

Line 6. Reporton this line the numberof ESL taxpayers
referredfor controversyrepresentation.
Returnand Other Tax Form PreparationActivities
Line 7. Ancillarymeansdirectlyrelatedto or secondaryto an
ESL outreach or educational activity. Thus, tax return
preparation
for an ESLonly clinicshouldbe limited.Taxpayers
that need current year tax return preparationshould be
referredto a VITA or TCE site. lf the tax returnpreparationis
it is not considered"ancillary"and
connectedto a controversy,
should not be reportedon this line: instead. it should be
reportedin Partll, line11.
Line 8. Preparationof lTlN applicationsis limited to two
contexts: (1) lf preparationis necessary to resolve the
taxpaye/s controversywith the lRS, or (2) lf preparationis
ancillaryto an educationalactivityof a taxpayerfor whom
Englishis a secondlanguage. Includeon this line only the
numberof lTlN applications
that fit into category(2). Category
(1) shouldbe reportedin Partll, line 12.

Part l. ESL, Publicity, and OutreachActivities
Report outreach activities based on the focus of the
outreach.
lf the outreach is marketedfor the ESL communityand it
includesinformationabout controversyservices,the outreach
shouldbe countedas an ESL outreach.
rorn'|3424-A

Number
53O4OU
1n"u.5-2010)Catalog

www.lrs.gov

RevenueService
Department
of the Treasury-lnternal

Instructionsfor the 2011Low IncomeTaxpayerClinicsInterimandYear-EndReportForm
Part ll. Controversy Activities
For the purposesof completingthis form, a case meansthe
clinic has entered into an agreement with the client for
representationinvolving a controversy with the Internal
RevenueService(lRS). A case includesall issuesfor one
taxpayerwith whom the clinicentersinto a pro bono or clinic
representation
agreement,or for whom the clinicobtainsa
Form 2848, Power of Attorney (POA) or other official
authorization.
Line 1. Report on this line the numberof cases that were
worked in the previousyear that remainedopen as of January
1. Thiswouldonly be reportedin column"i,"duringthe lnterim
reportingperiod.
Line 2. Reporton this linethe numberof new casesopened
in the reportingperiod.A case is also considerednew if the
issuewas closedin a priorreportingperiodand then reopened
to provideadditionalassistance.
Line 3. The total numberof open casesis the numberof cases
worked in the previousgrant year that remainedopen as of
January1, 2011, plus, the numberof new casesthat were
openedduringthe reportingperiod.
Line 3a. For informationon the poverty guidelines,see
Publication3319, Section lV. LITC PROGRAMGRANT
REQUIREMENTS.
Line 3b. The numberon this lineshouldequalline 36 on the
SuppfementallssuesForm(Form13424-8).
Line 3c. Enterthe numberof caseswherea petitionhas been
filedin the U.S.Tax Court.This may includecaseswherethe
petitionwas filed prior to this reportingperiodbut the clinicis
stillinvolvedwith the litigationduringthe reportingperiod.
Line 3d. Enterthe numberof refundsuitsfiledin a U.S District
Court or the U.S. Court of FederalClaims. This may include
cases where the complaintwas filed prior to this reporting
periodbut the clinicis still involvedwith the litigationduringthe
reportingperiod.
Line 3e. Enter the number of bankruptcycases where the
the clientwitha tax issue.
clinicis assisting
Line 3f. Enter the number of controversycases openedfor
ESL taxpayers.
Line 39. Includeon this line the total numberof caseswhere
the clinicenteredinto a representation
agreementand referred
the case to a qualifiedpro bono representative
to assist in
resolutionof the case.

Line 5. Consultationsare where brief advice or guidance
specific to the taxpayer's issue is given but no written
representation
agreementis enteredinto.This can occureither
by telephoneor in a face-to-facemeeting. Do not include
consultations
that occurredin the U.S. Tax Court, a U.S.
DistrictCourt,or the U.S. Court of FederalClaims;these will
be included
on lines6 or 7.
Line 6. Enteron this line all consultations
that occurredin the
U.S. Tax Court.For the definitionof consultation,
see the
instructions
for line5.
Line 7. Enteron this line all consultations
that occurredin a
U.S. DistrictCourtor the U.S. Courtof FederalClaims. For
the definitionof consultation,
for line 5.
see the instructions
Line 8. Includeon this lineconsultations
wherethe clientdid
not qualifyfor LITCservicesbut was referredto an alternative
professional
representative
to assistin resolutionof the case.
Line 9. Controversy
casescan sometimesinvolvea statetax
matterthat mustbe resolvedto movethe federalportionof the
caseto resolution.
Line 10. For reportingpurposes,preparationof a joint return
countsas two taxpayersassisted.lf representation
or referral
is providedto only one spouseon a joint return,the numberof
taxpayersassistedshouldbe reportedas one.
Line 10a. Enterthe numberof taxpayers,
from line 10, who
attendeda workshopand as a result becamea controversy
client.
Returnand Other Tax Form PreparationActivities
Line 11. This includesamendedreturnsand prioryear returns
that the clinicpreparedduringthis period.Taxpayersthat need
currentyear tax return preparationshould be referredto a
VITAor TCEsite.
Line 12. Preparation
of an lTlN application
shouldonly be
counted when it is necessary to resolve the taxpayer's
controversywith the lRS. This includes the taxpayer's
application
and any additionalapplications
for dependents.
GontroversyPublicity,and OutreachActivities
Reportoutreachactivitiesbasedon the focus of the outreach.
lf the outreachis marketedto discuss controversyservices
and a presentation
is includedabout ESL communityservices,
the outreachshouldbe countedas controversyoutreach.
Line 13. Outreachactivityis whenthe clinicinformsthe public
about clinic services by attending community events,
meetings,etc.

Line 3h. Includeon this line the total numberof caseswhere
the clinicenteredinto a representation
agreementand referred
the case to TAS for resolutionof the case.

Line 14. Enterthe numberof CPE or CLE sessionsheld to
recruitpro bonopanelmembers.

Line 4. A case is consideredclosed when the clinic is no
longer in a representationagreementwith the client. This
includes cases that were opened with a representation
agreementand then closeddue to non-responsiveness.

Line 15. Do not enterthe numberof ootentiallistener/viewers:
just reportthe numberof actualevents.The ProgramNarrative
is where you would reflect the size of the potential
listener/viewer
audience.

rorn13424-A

Number
53040U
1neu.5-2010)Catalog

www.rrs.gov

RevenueService
Department
of the Treasury-lnternal

Low IncomeTaxpayerGlinics (LlTGs)2011Supplementallssues
Nameof Glinic
Period

Report Type

!

InterimReport - January1 throughJune30, 2011 or !

E OriginalReport or I

Year-EndReport- January1 throughDecember31, 2011
For each column, enter the number of issues
worked for the reporting period

AmendedReport

Part l. Collection lssues

CollectionDue Process(CDP)

(OlC)
Offersin Compromise
(CNC)
CurrentlyNot Collectible
Part ll. Examinationlssues
EarnedIncomeTax Credit(EITC)
QuestionableTax ReturnPreoarers
(Non-EITC)
Officeor FieldExaminations
AutomatedSubstitutefor Return(ASFR)

Part lll. Miscellaneouslssues
Claimfor Refundor Requestfor Abatement
Relieffrom Jointand SeveralLiability(lnnocentSpouse)
IRC S 6672 Trust Fund RecoveryPenalty
OtherCivilPenalties

Individual
Taxpayerldentification
Numbers(lTlNs)
Determination
of WorkerStatus(FormSS-8/Form1099Misc.)
Part lV. Other lssues

Total Other lssues (including rssues listed on a separate sheet of paper)
Part V. Total lssues Reported
Enterthe total numberof issuesfor each reportingperiod.Add the amountsreported
on lines 10, 19, 32, & 35. Enterthe total here and on Form 13424-A,the 2011 Low
Income TaxpayerClinicslnterim and Year-EndReport,Part ll, line 3b.
rorn 13424-8

(n"u.5-2010) Catalog
Number
53041F

www.rrs.gov

RevenueService
Department
of the Treasury-lnternal

Instructionsfor the 2011 Low IncomeTaxpayerClinics (LITC)Supplementallssues Form
Note: When submitting your Interim or Year-End Report
package,this form is part of the ProgramNarrative.

Specificlnstructions

Under unusual circumstances,clinics may request an
extensionof time to submitthe InterimReportpackageor the
Year-EndReportpackage.Requestsfor an extensionmustbe
submittedin writingby e-mailto the cliniCsassignedprogram
analystpriorto the due date of the report.Once received,the
analystwill ask the Directorof the Low IncomeTaxpayerClinic
Programto reviewit and makea determination.

PartsI, ll and lll

Note: Failure to timely submit requiredreportsto the LITC
Program Office may result in freezingof funds, reductionof
futurefunds,or terminationof the grant.
Purpose
The SupplementallssuesForm is used by ControversyLITCs
to reoortclinicalwork on some of the mostcommontax issues
and capturesthe type of assistanceprovidedto taxpayers.
Note: Interim and Year-End Reports (includingthe report
forms containedin AppendixC) may be releasedunder the
Freedomof InformationAct (FOIA). In responseto a FOIA
request,the LITC ProgramOffice may releasethese reports
after appropriate redactions to ensure confidentialityof
taxpayerinformation.

For each issuelistedin Parts l, ll, and lll, providethe total
numberof issuesworkedduringthe reportingperiod.Cases
can involvemorethan one issueand each issuethat the clinic
is activelyworkingshouldbe reportedseparately.
Example 1: OrganizationA worked ten cases between
January1 and June 30. Eachcase has three issues- levy,
installmentagreement,and nonfiler. To completethis form
A wouldenter"10"on lines1, 8, and 30.
Organization
Example 2: OrganizationB worked a levy case that
developeda CDP issue. The issues in this case would be
countedon lines1 and4,
Example3: Organization
C workedwith a clientwho needed
an installmentagreementbut also had a lien filed. The client
does not have issuewith the federaltax lien and the clinic is
not activelytrying to resolvethe lien issue. The installment
agreementissuewould be counted,however,the lien issue
wouldnot.
Parts l. Collectionlssues

Reporting Requirements

Gounting an lssue. During the course of working a case
counteachissueonceas it is identifiedand worked.

Who should completethe SupplementallssuesForm?

Line 1. Levies. Reporton this line the numberof issues
worked during the reporting period where you assisted
taxpayerswith any levy issue, includinga noticeof intent to
levy, gettinga releaseof levy, or getting a return of levied
funds.

The Supplementallssues Form is to be completedby any
clinic reportingcases in Part ll, ControversyActivitiesof Form
13424-4. This form must be attachedto the Low Income
TaxpayerClinic(LITC)Interimand Year-EndReportpackages
for each reportingperiod.
Reporting period. Check all boxes that apply. LITCs are
required to report on clinic activitiestwice during the grant
cycle. The grantcycleis January1 throughDecember31 for
the year in which a grantaward is received.An InterimReport
is requiredfor the period January1 throughJune 30; the
Year-End Report is required for the period of January 1
throughDecember31.
lnterim reporting period. Complete column "i" for the
reportingperiodof January1 throughJune 30. In this column,
capture all issues currentlybeing worked that were carried
over from the previousyear and any new issuesthat were
workedJanuary1 throughJune30.
Year-End reporting period. Completecolumn "ii" reporting
issues for the period January 1 through December31.
Column "i" should have the totals previouslyreportedfor the
interim reporting period and column "ii" will be completed
reflectingthe total activitythat occurredduring the reporting
periodof January 1 throughDecember31. In this column,
captureall issuesworkedfor the year by addingcolumn"i" to
the number of new issuesworked July 1 throughDecember
31.

r"rm 13424-8

1neu.5-2o1o) catalogNumber53041F

Line 2. Liens. Reoorton this line the numberof issues
worked during the reporting period where you assisted
taxpayerswith a lien issue, includinga notice of lien, a
dischargeof lien, a subordination
of lien, withdrawalof a lien,
certificates
of non-attachment.
or a releaseof lien.
Line 3. Payments.Reporton this linethe numberof issues
duringthe reportingperiodwhereyou assistedtaxpayerswith
a paymentissue,includinga lost payment,tracinga payment,
or makinga payment.
Line 4. Collection Due Process (CDP). Reporton this line
the numberof issuesworkedduringthe reportingperiodwhere
you assistedtaxpayerswith a collectiondue processissue.
Line 5. Collection Appeals Program (CAP). Reporton this
linethe numberof issuesworkedduringthe reportingperiod
where you assistedtaxpayerswith any collectionappeals
rssue.
Line 6. Bankruptcy.Reporton this line the numberof issues
worked during the reporting period where you assisted
taxpayerswith any tax-relatedbankruptcyissue, includinga
dischargeof bankruptcyor notifyingthe IRS of bankruptcy
status.

www.rrs.gov

Departmentof the Treasury-lnternalRevenue Service

lssuesForm
Instructionsfor the 2011Low IncomeTaxpayerClinics(LITC)Supplemental
Line 7. Offers in Gompromise (OlC).Reporton this linethe
number of issues worked during the reportingperiodwhere
you assisted taxpayers with an OIC issue, including
submissionof an OlC, the processingof an OIC or the
rejectionof an OlC.
Line 8. Installment Agreements (lA). Reporton this line the
number of issues worked during the reportingperiodwhere
you assistedtaxpayerswith an installmentagreementissue,
includinga requestfor an lA, the denialof an lA, or defaultof
an lA.
Line 9. GurrentlyNot Collectible(GNG).Reporton this line
the numberof issuesworkedduringthe reportingperiodwhere
you assistedtaxpayerswith a CNC issue,includinga request
for CNC statusor workingwith the IRS to ensurethe account
is correctlycodedfor CNC status.

Line 16. Automated Substitute for Return (ASFR).Report
on this linethe numberof issuesworkedduringthe reporting
period where you assisted taxpayers with an ASFR
assessmentissue.Thistypicallyinvolvesissueswherethe IRS
determinesthe correcttax liabilityby computingtax, penalties,
and interest,basedupon InformationReportingProgram(lRP)
information submitted by payors, combined with other
internallyavailableinformation.
Line 17. Automated Underreporter(AUR). Reporton this
linethe numberof issuesworkedduringthe reportingperiod
where you assisted taxpayers with an Automated
(AUR) Programissue.Taxpayersare typically
Underreporter
notifiedof an AUR issue through CP 2000 notices. This
processis part of the InformationReportingProgram,where
the IRS matches third-partyinformationreturns to identify
incomeand deductionsthat do not appearto be reportedon
tax returns.

Line 10. Total Collectionlssues. Add lines1 through9.

Part ll. Examinationlssues
Counting an lssue. During the course of working a case,
counteach issueonce as it is identifiedand worked.
Line 11. EarnedIncomeTax Gredit(EITC). Reporton this
line the numberof issuesworked duringthe reportingperiod
where you assistedtaxpayerswith an EITCExaminationissue
(correspondenceexam or field exam) including EITC
Certification
issues.
and EITC Recertification
Line 12. QuestionableTax Return Preparerlssues. Report
on this line the number of issues worked during the period
where you providedassistanceto taxpayersas a resultof the
practicesby questionabletax returnpreparers.
Line 13. Other CorrespondenceExaminations(non-EITC)
Report on this line the number of issuesworked during the
reporting period where you assisted taxpayers with a
correspondenceexam issue other than an EITC Exam,EITC
Certification, or EITC Recertification. Office or field
examinationissuesshouldbe reportedon line 14.
Line 14. Office or Field Examinations(non-EITG).Report
on this line the numberof issuesworkedduringthe reporting
period where you assistedtaxpayerswith an office or field
examination. An office or field examination involves a
face-to-facemeeting with an examiner or revenue agent.
Examinationsconductedthroughcorrespondence
from an IRS
campusare reportedon line 13.
Line 15. Audit Reconsideration.Reporton this line the
number of issues worked during the reportingperiodwhere
you assistedtaxpayerswith an audit reconsideration.
An audit
reconsiderationis an IRS procedure designed to help
taxpayerswhen they disagreewith the resultsof an audit of
their tax return or a return the IRS created for taxpayers
becausethey did not file a tax return.

ror^13424-8

Number53041F
1n"u.5-2010) Catalog

Line 18. Amended Returns. Reporton this line the number
of issues worked during the reporting period where you
assistedtaxpayerswith a Form 1040Xissue. Form 1040X is
usedto changethe originalreturnto includenew information.
(A filedreturncan includean SFR or an originalreturn).
Line 19. TotalExaminationlssues.Add lines11 through18.

Part lll. Miscellaneous
lssues
Gounting an lssue. During the course of working a case,
counteachissueonceas it is identifiedand worked.
Line 20. Appeals. Reporton this linethe numberof issues
worked during the reporting period where you assisted
taxpayerswith an Appealsconferenceor hearing,except for
CDP issues (reportthese on line 4) or CAP issues (report
theseon line5).
Line 21. Claim for Refund or Request for Abatement.
Reporton this line the numberof issuesworked during the
reportingperiodwhere you assistedtaxpayerswith a Form
843 issue.Form 843 is used to claim a refundor requestan
abatementof certaintaxes,interest,penalty,and additionsto
tax.
Line 22. First-Time Homebuyer Credit. Reporton this line
the numberof issuesworkedduringthe reportingperiodwhere
you assistedtaxpayerswith any First-TimeHomebuyerCredit
rssue.
Line 23. Relief from Joint and Several Liability (lnnocent
Spouse). Reporton this line the number of issues worked
duringthe reportingperiodwhereyou assistedtaxpayerswith
any innocent spouse relief issue, whether the relief was
grantedor not. Do not includeon this line InjuredSpouse
issues;theseissuesshouldbe reportedon line24.
Line 24. Injured Spouse Glaim. Report on this line the
numberof issuesworked during the reportingperiod where
you assistedtaxpayerswith an injuredspouseclaim or issue.
Whena joint returnis filedand the refundis appliedtowardthe
one spouse'spast due debt and the other spouse (injured
spouse)is not legallyliable,the spousewho is not liableis the
injuredspouse.

www.rrs.gov

RevenueService
Department
of the Treasury-lnternal

Instructionsfor the 2011Low IncomeTaxpayerClinics(LITC)SupplementallssuesForm
Line 25. IRC S 6672 Trust Fund Recovery Penalty. Report
on this line the numberof issuesworkedduringthe reporting
period where you assisted taxpayers with Trust Fund
Recovery Penalty (TFRP) issues. The TFRP is a penalty
providedby IRC section6672 againstany personrequiredto
collect, account for, and pay over taxes held in trust who
willfullyfails to performany of theseactivities.
Line 26. Other Givil Penalties. Report on this line the
number of issues worked during the repoftingperiod where
you assistedtaxpayerswith other civil penaltiesissues.Civil
penaltiescan be assessedin severalinstancesincluding,for
failure to timely file a federal tax return, substantial
understatementof tax, understatinga reportabletransaction,
filing an erroneousclaim for refundor credit,filinga frivolous
tax submission,or failing to supply an SSN or individual
taxpayeridentification
number.
Line 27. ldentity Theft. Report on this line the number of
issuesworkedduringthe reportingperiodwhereyou assisted
taxpayerswho self-identified
themselvesas a victimof identity
theft or receiveda letteror noticefrom the IRS that leadsthem
to believesomeonehas usedtheirsocialsecuritynumber.

Part lV. Other lssues
Counting an lssue. Duringthe courseof workinga case,
counteachissueonceas it is identifiedand worked.
For issuesnot listedon this form, indicatethe specificissue
and the numberof times you worked that issue during the
reportingperiod. lf additionalspace is needed, attach a
separatesheetof paperlistingthe reportingperiod,the issue,
and the numberof timesthe issueoccurred. At the top of the
separatesheet, identifyyour organizationand the reporting
period.
Line 33. Reporton this line any issuesthat were not listedin
Partsl, ll, and lll.
Line 34. Reporton this line any issuesthat were not listedin
P artsl , l l , andl l l .
Line 35. Total Other lssues. Add lines33, 34 and the totalof
issuesreportedon the separatesheetof paper,if applicable.

Line 28. Cancellationof Debt (COD).Reporton this linethe
number of issues worked during the reportingperiodwhere
you assistedtaxpayerswith a debt that was eithercancelledor
forgiven. This amount may be taxable dependingon the
circumstances.
Line 29. Individual Taxpayer ldentification Numbers
(lTlNS). Report on this line the number of issues worked
duringthe reportingperiodwhere you assistedtaxpayerswith
the preparationor processingof lTlN applications.
Line 30. Nonfiler. Reoorton this linethe numberof issues
worked during the reporting period where you assisted
taxpayerswho had a filingrequirementfor a previousyear but
failedto file theirtax return(s).
Line 31. Determinationof Worker Status (Form SS-8/Form
1099 Misc.). Reporton this line the numberof issuesworked
duringthe reportingperiodwhere you assistedtaxpayerswith
employeevs. independentcontractorissues.
Line 32. Total Miscellaneouslssues. Add lines20 through
31.

rorn 13424-8

Number
5-2010) Catalog
53041F
1Rev.

www.rrs.gov

Departmentof the Treasury-lnternalRevenue Service

Low IncomeTaxpayerGlinics(LlTGs)
Advocacy lnformation
Reporting Period

!

InterimReport - January1 throughJune30, 2011 or !

Year-EndReport- January1 throughDecember31, 2011

Nameof Clinic

Part l. SystemicAdvocacy Submissions
Completethe followingsectionto identifyissuessubmittedto educateor advocatefor low incomeor ESLtaxpayerson the Systemic
additional pages as

lssue number

Datesubmitted

Briefdescriotionof the issue

Briefdescriptionof the issue

Briefdescriptionof the issue

Briefdescriptionof the issue

Part ll. PublishedMaterials
Completethe followingsectionto identifyarticleswrittento educateor advocatefor low incomeor ESLtaxpayers.
(Attachadditional paqesas necessary)
Source ! eoot
! LawReview ! Magazine ! Newspaper ! weosite ! otner
Author'sname
Datepublished
Titleof article

Publication
or Website

Briefdescriptionof the article

Source

f] eoot

!

Law Review

!

Magazine

Author'sname
Titleof article

!

Newspaper I weusite !
Datepublished

otner

Publication
or Website

Briefdescriptionof the article

rorn13424-C

Number36126D
1+-zoro1 Catalog

www.rrs.gov

Departmentof the Treasury-lnternalRevenue Service

LITCsAdvocacy Informationcontinued
Part ll. PublishedMaterials(continued)
Source ! eoot
Author'sname

!

LawReview !

Magazine I

Newspaper ! website !
Dateoublished

otner

Publication
or Website

Titleof article
Briefdescriptionof the article

Source I aoor
Author'sname

I

LawReview

fl Magazine

Title of article

Newspaper Ll Website

Dateoublished
Publication
or Website

Briefdescriptionof the article

Part lll. Television and Radio Appearances
that educatedor advocatedfor low incomeor ESL
Completethe followingsectionto identifytelevisionand radioappearances
ta
Airing dates of segment
Numberof potentiallistenersor viewers
Discussion
topic
Briefdescriptionof the topic

Airing dates of segment

Numberof potentiallistenersor viewers

Discussiontopic
Briefdescriptionof the topic

Airing dates of segment

Numberof potentiallistenersor viewers

Discussion
tooic
Briefdescriptionof the topic

Airing dates of segment

Numberof ootentiallistenersor viewers

Discussiontopic
Briefdescriptionof the topic

Number36126D
rorn 13424-G 1+-zorol catatog

www.rrs.gov

RevenueService
Department
of the Treasury-lnternal

Volunteer/ Pro BonoTime
per OMB A-110, LITCSare requiredto trackthe amountof timevolunteers
spendworkingon LITCactivities
or probonomembersuseto resolvea client'sissue(s)
Use thisformto documentthe amountof timevolunteers

Activities and Time Reporting (reportedin hours)

Activity Date

r"r

13424-F

Volunteer'sName

G-zoto\ catalogNumber54952J

www rrs.gov

Departmentof the Treasury-lnternalRevenue Seryice