Form 13424 Low Income Taxpayer Clinic (LITC) Application Informatio

Form

Department of the Treasury - Internal Revenue Service

13424

OMB Number
1545-1648

Low Income Taxpayer Clinic (LITC)
Application Information

(April 2018)
Grant Period Request (Check one)
New application

Single year

Multi-year

Non-Competitive continuation

Second year

Third year

Grant amount requested (maximum $100,000)

Applicant Information
Legal name of sponsoring organization
Prefix

Last name

First name

Middle initial

Suffix

State

ZIP + 4 code

Title
Phone number

FAX number

Email address

Applicant's Mailing Address
Street
Street address line 2
City

Clinic Information
Name of clinic
Public telephone number

Toll-Free telephone number (if applicable)

FAX number

Website address (if applicable)
Languages served in addition to English
Clinic Street Address

Clinic Mailing Address

Street

Street

City

State

ZIP + 4 code

City

State

ZIP + 4 code

Middle initial

Suffix

Clinic Director Information
Prefix

Last name

First name

Telephone number

Email address

Licenses/Certifications (Check all that apply)
Attorney

CPA

Catalog Number 36126D

Enrolled Agent

Other

www.irs.gov

Form 13424 (Rev. 4-2018)

Page 2

Qualified Tax Expert (QTE)
Prefix

Last name

First name

Telephone number

Middle initial

Suffix

Middle initial

Suffix

Middle initial

Suffix

Email address

Licenses/Certifications (Check all that apply)
Attorney

CPA

Enrolled Agent

Other

Qualified Business Administrator (QBA)
Prefix

Last name

Telephone number

First name
Email address

Tax Compliance Officer
Prefix

Last name

First name

Title
Telephone number

Email address

Instructions for Form 13424, Low Income Taxpayer Clinic (LITC) Application Information
Purpose
This form is used to report basic information about the applicant, including the amount and period of the grant requested, contact
information for the applicant’s sponsoring organization, the name and location of the clinic where services are provided, and key clinic
staff members. The Program Office uses the information reported on this form to correspond with clinics and to publicize the location of
service providers to taxpayers in IRS publications and online. Please follow the instructions carefully and report all information
completely and accurately. A complete response means an entry must be provided for each field.
Who Must Complete This Form
All organizations submitting a Full Grant Application or a Non-Competitive Continuation (NCC) Request must complete this form. See
Publication 3319, Section IV, Application and Submission Process.
Any forms submitted with a Full Grant Application or NCC Request may be released under the Freedom of Information Act (FOIA). In
response to a FOIA request, the LITC Program Office will release these forms after appropriate redactions to ensure confidentiality of
taxpayer information.
Specific Instructions
Grant Period Request
Check the appropriate box to indicate whether a single or multi-year grant is requested. Under IRC § 7526, the LITC Program Office is
authorized to issue grants for a period of up to three years. Applicants that have never been awarded an LITC grant are not eligible for
a multi-year grant and may only request a single year grant.
Current grantees requesting a NCC Request must check the box indicating whether the request is for the second or third year of a
multi-year grant.
Enter the total amount, rounded to whole dollars, of funding requested for the grant year. The maximum funding that may be awarded
for any grant year is $100,000.
Applicant Information
Enter the contact information for the organization applying for the grant. The name of the applicant must match exactly the name used
to register with the System for Award Management (SAM). If a grant is awarded, the award will be payable to the organization listed in
this section.
For Applicant’s Mailing Address, please provide a complete response, including zip plus-four code. Phone numbers should be
formatted as 123-456-7890 x.111.
Clinic Information
This section is used to report information about the clinic where services are provided to taxpayers. If a grant is awarded, the
information entered in this section will be used exactly as entered to prepare IRS Publication 4134, Low Income Taxpayer Clinic List.
Publication 4134 is the primary tool for many low income and ESL taxpayers to locate LITC services. Thus, the clinic name entered
should be the name used in materials publicizing the LITC’s services to taxpayers and the public.
Catalog Number 36126D

www.irs.gov

Form 13424 (Rev. 4-2018)

Page 3

Instructions for Form 13424, Low Income Taxpayer Clinic (LITC) Application Information (cont'd)
Please provide a complete response, including zip plus-four code, for the Clinic Street Address, and Clinic Mailing Address. Do not
write “same.” Phone numbers should be formatted as 123-456-7890 x.111.
When providing the clinic’s website address, please provide the direct link to the LITC page if one is available. If no website exists, write
“none.”
Please individually list all languages in addition to English in which services can be provided on site. If the clinic uses a telephone or
internet based translation service, state “other languages through interpreter services.”
All applicants must identify a Clinic Director, Qualified Expert (QTE), and Qualified Business Administrator (QBA) responsible for clinic
operations and management of funds. For more information on these positions, see Publication 3319, Section VI.C.i, Standards for
Operating an LITC. For the clinic director and QTE, list any applicable licenses and certifications.
Tax Compliance Officer
All applicants must identify a Tax Compliance Officer. See Section III.C.iii, Compliance with Federal Tax and Nontax Requirements and
Glossary for a discussion of who may be designated.
An applicant must be in full compliance with its federal tax responsibilities when applying for an LITC grant and throughout the grant
year.

Catalog Number 36126D

www.irs.gov

Form 13424 (Rev. 4-2018)