Form 14417 Form 14417 Reimbursable Agreement--Non-Federal Entities

Form

Department of the Treasury - Internal Revenue Service

14417

(August 2012)

Reimbursable Agreement - Non-Federal Entities
(State and Local Governments, Foreign Governments, Commercial Organizations, and Private Businesses)

Legal Terms and Conditions incorporated by reference on page 3
1a. IRS agreement tracking number (reimb agreement + fiscal Year + B + project number)

1b. IRS unique customer number

2. Program contact information (for all inquires other then those related to advance payment)
Buyer Representative

Seller - IRS Business Unit Reimbursable Coordinator

a. Official's name

a. Official's name

b. Official's title

b. Official's title

c. Organization name

c. IRS Business Unit name

d. Address:
i. Street number

d. Address:
i. Street number

ii. Street name

ii. Street name

iii. City

iii. City

iv. State

iv. State

v. ZIP code

v. ZIP code

e. Telephone number

e. Telephone number

f. FAX number

f. FAX number

g. Email address

g. Email address

3. Statutory authority
Internal Revenue Code (Sections 6103(p)(2), 6108(b), 6103(p)(4), 7213,
7213A, 7431) addresses authority to enter into reimbursable agreements,
safeguarding and protection of tax return information, among other provisions
impacting funds in reimbursable. See also the Legal Terms and Conditions,
Section 1 on page 3 of this form.

Other Statutory Authority superseding and/or providing more specific authority
than the IRC. For example, the Foreign Assistance Act of 1961 (22 U.S.C. 2357)
provides more specific authority and requirements for reimbursable agreements
with foreign non-federal entities.

4. Agreement action
Increase
New

Cancellation

Amendment (increase or decrease)
Decrease

5. Agreement period of performance
a. Start date
MM-DD-YYYY

b. End date
MM-DD-YYYY

Note: Enter the estimated completion (End) date for support under this agreement.
IRS agreements operate on a fiscal year basis and do not cross fiscal years.

c. Cancellation date
MM-DD-YYYY

6. Description of requested products and/or services to be provided (provide sufficient detail to allow the federal government to effectively cost
products and/or services for the agreement period)

Catalog Number 59893X

www.irs.gov

Form 14417 (8-2012)

Page 2 of 5
7. Advance payment requirements
All non-federal entities must provide an advance payment before the IRS begins any work for the full costs of goods and/or services
ordered.
For IRS Use Only: Once work has been completed and revenue earned, a commensurate amount will be drawn down against the
advance payment using one of the following draw-down options.
Monthly

Quarterly

Lump-Sum/One-Time - Products and/or services may be provided once or
multiple times, however the full amount of earnings are recognized the first
time a product is delivered and/or a service is rendered.

8. Breakdown of reimbursable cost estimate
Unit of measure applicable to project
Item quantity (A)
Unit price (B)

$
Total estimated costs at left must agree with the
Total current reimbursable agreement amount.

Total direct costs (A x B) $
Indirect/Overhead costs $
Total estimated costs $
Initial reimbursable agreement amount (including any prior amendments)

$

Current amendment - increase (decrease)

$

Total current reimbursable agreement amount

$

9. Billing and collection contact information and payment requirements
Non-Federal Entities must provide a valid Taxpayer Identification Number (TIN) or Employee Identification Number (EIN). The Dun and
Bradstreet Universal Number System (DUNS) is the vendor data network used by the IRS. Insert TIN/EIN and DUNS numbers below.
Submit advance payment to the mailing address referenced below.
Buyer (organization name)

Seller

Internal Revenue Service

Government Payables and Receivable Section (GPRS) (Advance

Finance Office Representative

Payment Inquiries Only)

a. Official's name

a. IRS Office name

GPRS Helpdesk

b. Official's title

b. Telephone number

(304) 254-3359

c. Billing address:
i. Street number

c. FAX number

(304) 254-5976

d. Email address

[email protected]

e. TIN/EIN

52-1782822

ii. Street name
iii. City
iv. State
v. ZIP code

Make advance payments to:
Internal Revenue Service
Beckley Finance Center
P.O. Box 9002
Beckley, WV 25802-9002

d. Telephone number
e. FAX number
f. Email address
g. TIN/EIN
h. DUNS
Payment method:
Paper check

Electronic check via Pay.gov

Money order

Other

10. Authorizing/Approving official information
Buyer (organization name)
a. Official's name

Seller
a. Official's name

b. Official's title

b. Official's title

c. Telephone number

c. Telephone number

d. Email address

d. Email address

e. Signature/Date

e. Signature/Date

Catalog Number 59893X

www.irs.gov

Internal Revenue Service

Form 14417 (8-2012)

Page 3 of 5
10a. Co-Signature for authorizing/approving official (as appropriate)
Buyer (organization name - optional)
a. Official's name

Seller
a. Official's name

b. Official's title

b. Official's title

c. Telephone number

c. Telephone number

d. Email address

d. Email address

e. Signature/Date

e. Signature/Date

For example, a Buyer may require more then one approving official to ratify
a reimbursable.

For example, co-signatures from approving officials in more then one
business unit may be required under statutory authorities governing
reimbursable agreements with foreign entities.

Internal Revenue Service

Legal Terms and Conditions
1. IRS Reimbursable Authority: The authority to perform services on a cost reimbursable basis is contained in sections
6103(p)(2) and 6108(b) of the Internal Revenue Code (IRC). Performance of services is authorized only when consistent
with the basic public obligations of the Internal Revenue Service (IRS). If necessary to fulfill its public obligations, the IRS
may modify, reject, cancel, or terminate any part of this agreement and return the unused balance of funds advanced.
1a. Section 6103(p)(4) of the IRC provides specific requirements for Federal, state, and local organizations to safeguard
Federal tax returns and return information as a condition of receiving the information. IRS Publication 1075, Tax
Information Security Guidelines for Federal, State, and Local Agencies (OMB No. 1545-0962) provides additional
guidelines.
1b. Section 7213 of the IRC makes unauthorized disclosure of a return or return information a felony punishable by a fine
not to exceed $5,000 or imprisonment of not more than 5 years, or both, together with the costs of prosecution. Section
7213A makes unauthorized inspection of a return or return information punishable by a fine up to $1,000, or imprisonment
of not more than one year, or both, together with the costs of prosecution. Section 7431 makes persons who knowingly or
negligently make an unauthorized disclosure of a return or return information liable for civil damages.
2. IRS Costing: The IRS will charge for direct and indirect/overhead costs for reimbursable work. If funds advanced to
the IRS are more than the actual cost of performing the work, the difference will be returned to the buyer. If the advance
received is less than the actual costs incurred, the buyer agrees to pay for the additional costs incurred and an amended
Form XXXX indicating the increase in costs must be submitted along with additional funds. See OMB Business Rules for
Advance Payment Policies. IRM 1.33.3, Strategic Planning, Budgeting and Performance Management Process;
Reimbursable Operating Guidelines contains the IRS regulations applicable to costing its reimbursable agreements.
3. Work Delays and Errors: Although the IRS will make every reasonable effort to avoid delays and errors in the
performance of this agreement, the IRS is not responsible for the buyer’s costs incurred due to any such delays or errors.
The buyer must pay for the cost of data recompilations or corrections.
4. Data Recordkeeping: The IRS reserves the right to use a copy of all data provided under this agreement.
5. Cancellations: Either the non-federal entity (Buyer) or the IRS (seller) may cancel this agreement by giving written
notice to the other party 30 days before cancellation. Payment to the IRS shall include actual costs incurred through the
cancellation date, plus any termination costs. The IRS will exercise due diligence to prevent incurring costs after the
cancellation date. However, the buyer shall also reimburse the IRS for unavoidable commitments up to the date the
agreement would have expired. When an accepted order is cancelled by the buyer, the seller is authorized to collect
actual costs incurred through the cancellation date, plus any termination costs.
6. Dispute Resolution: Disputes and major differences between non-federal entities and the IRS shall be resolved in a
similar manner to the business rules set out in the Treasury Financial Manual, Volume 1, Bulletin No. 2011-04,
Intragovernmental Business Rules, dated November 8, 2010. See also: http://fms.treas.gov/tfm/vol1/11-04.pdf.
7. Agreement Reference: All communications between parties must refer to the Agreement by the “Project Agreement
Number” (e.g. RA20XXBXXX).

Catalog Number 59893X

www.irs.gov

Form 14417 (8-2012)

Page 4 of 5

Instructions for Form 14417, Reimbursable Agreement - Non-Federal Entities
(State and Local Governments, Foreign Governments, Commercial Organizations, and Private Businesses)
Note: All information must be typed into the Reimbursable Agreement (Form 14417) other than Authorizing/Approving Officials'
Signatures.
Field
Number

1.a.

1.b.
2.

Field Name

IRS Agreement Tracking Number

Field Action
Enter the IRS-assigned agreement tracking number (e.g. RA20XXBXXX). The numbering scheme is
made up of 4 accounting sections: RA (Reimbursable Agreement); 20XX (fiscal year); B (Alpha
Standard) and XXX (Unique IFS Internal Order Code for the project). Contact the IRS/ Chief Financial
Officer/Corporate Budget to establish new agreement tracking numbers. For agreements recurring from
year-to-year, use existing agreement tracking numbers, updated to reflect the current fiscal year (e.g.
RA2011B001 to RA2012B001).
Enter the IRS-established unique customer number for the non-federal entity. The IRS Beckley Finance
Center will provide new customer numbers once a signed agreement is received. For non-federal
agreements that recur from year-to-year, IRS Business Unit Reimbursable Coordinators and Project
Coordinators should continue to use the same customer numbers.

2.a.
2.b.
2.c.

IRS Unique Customer Number
Program Contact Information
Buyer Representative
Official's Name
Official's Title
Organization Name

2.d.

Address

Enter Buyer's Program Representative official's address - street number, street name, city, state, and zip
code.

2.e.
2.f.
2.g.

Telephone Number
Fax Number
Email Address

Enter Buyer's Program Representative official's telephone number related to the reimbursable
agreement.
Enter Buyer's Program Representative official's fax number related to the reimbursable agreement.
Enter Buyer's Program Representative official's email address related to the reimbursable agreement.

Enter Buyer's Program Representative official's name.
Enter Buyer's Program Representative official's title.
Enter Buyer's Organization Name.

Seller - Business Unit Reimbursable
Coordinator

2.a.
2.b.
2.c.

Official's Name
Official's Title
IRS Business Unit Name

Enter IRS Business Unit Reimbursable Coordinator official's name who will be certifying that advance
payment(s) have been received, confirming work completion, and product delivery and/or services being
rendered.
Enter IRS Business Unit Reimbursable Coordinator official's title.
Enter IRS Business Unit Name.

2.d.

Address

Enter IRS Business Unit Reimbursable Coordinator official's address - street number, street name, city,
state, and zip code.

2.e.

Telephone Number

Enter IRS Business Unit Reimbursable Coordinator official's telephone number related to the
reimbursable agreement.

2.f.

Fax Number

Enter IRS Business Unit Reimbursable Coordinator official's fax number related to the reimbursable
agreement.

2.g.

Email Address

Enter IRS Business Unit Reimbursable Coordinator official's email address related to the reimbursable
agreement.

3.

Statutory Authority

4.

Agreement Action

Internal Revenue Code section references box is pre-populated. These statutory references always
apply. Other Statutory Authority - This box should be checked when additional statutory authority
applies. Enter additional statutory authority on the line provided, if applicable.
Enter agreement-related action type. (e.g., New, Amendment, or Cancellation)
1) Either New or Amendment must be checked.
2) If Amendment is checked, then either Increase, Decrease or Cancellation must be checked.

5.

Agreement Period of Performance

Enter the following information:
1) The start date of the agreement (effective date)
2) The end date of the agreement (the estimated completion date for support under this
agreement). Note: IRS agreements operate on a fiscal year basis. Funding received from state,
local and foreign governments applies to the current fiscal year only. Multi-year funding cannot be
retained or applied to future fiscal years.
3) Enter the cancellation date of the agreement, if applicable.

6.

Description of Requested Products and/
or Services to be Provided

Enter a description of requested products and/or services to be provided by the IRS, including scope of
work or work statement to support delivery orders.
"Non-federal customers must provide an advance payment before the IRS begins any work for the full
cost of goods and/or services to be provided.

7.

Advance Payment Requirements

Indicate the type of drawn down method to be used: One box must be checked which denotes the
frequency of revenue recognition and frequency of the advance draw down, monthly is the
recommended frequency."

Breakdown of Reimbursable Cost
Estimate
8.

Unit of Measure Applicable to Project

Catalog Number 59893X

Indicate the unit of measure that will be used to cost the project.

www.irs.gov

Form 14417 (8-2012)

Page 5 of 5
Field
Number

Field Name

Field Action

Item Quantity (A)

Enter the number of items, hours, or other unit of measure related to the project, if applicable.

Unit Price (B)
Total Direct Costs (A X B)

Enter the unit price of product being delivered or service being provided related to the project, if
applicable.
Enter total direct costs. See IRM 1.33.8 Reimbursable Operating Guidelines - Costing.

Indirect/Overhead Costs
Total Estimated Costs

Enter the total indirect/overhead costs. Examples of Indirect/Overhead Costs include: a) General
management and administrative services, b) Facilities management and ground maintenance services
(security, rent, utilities, and building maintenance), c) Procurement and contracting services, d) Financial
management and accounting services, e) Information technology services, f) Services to acquire and
operate property, plant and equipment, g) Publication, reproduction, graphics and video services, h)
Research, analytical, and statistical services, i) Human resources/personnel services, and j) Library and
legal services. See IRM 1.33.8 Reimbursable Operating Guidelines - Costing.
Enter the total amount of estimated costs which equals direct and indirect/overhead costs.

Initial Reimbursable Agreement Amount,
including any prior amendments

Enter the Initial Reimbursable Agreement amount or the Initial Reimbursable Agreement amount
adjusted for any increases or decreases before the most recent amendment.

Current Amendment - Increase
(Decrease)

Enter the current amendment amount - increase/decrease, as applicable.

Total Current Reimbursable Agreement
Amount

Enter the summation of the Initial Reimbursable Agreement Amount, including any prior amendments
and Current Amendment - Increase/Decrease fields.

9.a.
9.b.

Billing & Collection Contact Information
and Payment Requirements
Finance Office Representative
Official's Name
Official's Title

Enter Buyer's Finance Office Representative official's name.
Enter Buyer's Finance Office Representative official's title.

9.c.

Billing Address

Enter Buyer's Finance Office Representative official's address - street number, street name, city, state,
and zip code.

9.d.

Telephone Number

Enter Buyer's Finance Office Representative official's telephone number for correspondence on billing
and collection issues.

9.e.

Fax Number

Enter Buyer's Finance Office Representative official's fax number for correspondence on billing and
collection issues.

9.f.
9.g.
9.h.

Email Address
TIN/EIN
DUNS

Enter Buyer's Finance Office Representative official's email address for correspondence on billing and
collection issues.
Enter Buyer's valid Taxpayer Identification Number (TIN) or Employee Identification Number (EIN).
Enter the Buyer's Dun and Bradstreet Universal Numbering System (DUNS).

9.a.
9.b.
9.c.
9.d.
9.e.

Seller - Government Payables and
Receivable Section
IRS Office Name
Telephone Number
Fax Number
Email Address
TIN/EIN

Pre-populated with BFC GPRS Helpdesk.
Pre-populated with BFC GPRS Helpdesk telephone number.
Pre-populated with BFC GPRS Helpdesk fax number.
Pre-populated with BFC GPRS Helpdesk email address.
Pre-populated with IRS Taxpayer Identification Number (TIN).

Payment Method

Enter payment method option: 1) Paper Check, 2) Electronic Check via Pay.Gov, 3) Money Order, or 4)
Other. If another method is selected, describe the method used. One box must be checked.

8. (con.)
9.

10.
10.a.
10.b.
10.c.
10.d.

10.e.
10.a.
10.b.
10.c.
10.d.

10.e.

Authorizing/Approving Official
Information
Buyer
Official's Name
Official's Title
Telephone Number
Email Address

Signature / Date
Seller
Official's Name
Official's Title
Telephone Number
Email Address

Signature / Date

Catalog Number 59893X

Additional Buyer and Seller Authorizing/Approving information fields are included in cases when a
program requires multiple Authorizing/Approving officials.
Enter Buyer's Authorizing/Approving official's name.
Enter Buyer's Authorizing/Approving official's title.
Enter Buyer's Authorizing/Approving official's telephone number.
Enter Buyer's Authorizing/Approving official's email address.
The Buyer's Authorizing/Approving Official must sign and date to authorize the purchase of products and/
or services provided on behalf of the requesting entity. Work on the project will not begin until the sign-off
has occurred.
Enter IRS Authorizing/Approving official's name. Must be an IRS Employee.
Enter IRS Authorizing/Approving official's title.
Enter IRS Authorizing/Approving official's telephone number.
Enter IRS Authorizing/Approving official's email address.
The IRS Authorizing/Approving Official must sign and date to authorize the funding of products and/or
services provided to the buyer on behalf of the seller. Work on the project will not begin until the sign-off
has occurred.

www.irs.gov

Form 14417 (8-2012)