Form 10574 - Community Based Outlet Program - Department Of Treasury
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1Community Based Outlet Program
OMB 1545-1753
Section 1 - Type of Contact
Please date and check the appropriate box.
Date ___________________
Corporation
Copy Center
Grocery Store
City/County Government
Credit Union
Pharmacy
Newspaper
Other ___________________
Section 2 - Contact Information
Please print.
Participant ________________________________________________________________________________
Address _________________________________________________ Suite/Apt. No. _____________________
City _____________________________________________________ State __________
ZIP ___________
Contact Person ____________________________________________________________________________
Phone Number (______) __________________ Ext. _____________
E-mail Address ____________________________________________________________________________
Section 3 - Other Informational Needs
Your special needs or interests are...?
EITC
VITA
(Earned Income Tax Credit)
Small Business/Self Employed
(Volunteer Income Tax Assistance)
Reproducible Federal Tax Products
Electronic Filing
TCE
(e-file)
(Tax Counseling for the Elderly)
Other
(Please specify) ________________________________________________________________________________________
Instructions for Form 10574
Purpose - Form 10574 is used by potential outlets that may want to participate in the Community Based Outlet Program or
that require additional information concerning the program parameters or services provided.
Section 1, Type of Contact - Check the box that most closely describes your type of entity. If none of the options describes
the outlet, check the "other" box and describe in the space provided.
Section 2, Contact Information - Please provide complete contact information.
Section 3, Other Informational Needs - Check the appropriate boxes and/or provide additional information if the "other" box
is selected.
Fax completed form to: (309) 662-2432
Customer Service: (800) 829-2765
Paperwork Reduction Act Notice
We ask for information on this form to carry out the Internal Revenue laws of the United States. Your response is voluntary.
You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the
form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as
their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and information
are confidential, as required by Code section 6103.
The time needed to complete this form will vary depending on the individual circumstances. The estimated average time is 5
minutes. If you have comments concerning the accuracy of this time estimate or suggestions for making this form simpler, we
would be happy to hear from you. You can write to the Internal Revenue Service, Tax Products Coordinating Committee,
SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave NW, Washington, DC 20224. Do not mail your Form 10574 to this address.
10574
Catalog Number 25090G
Department of the Treasury-Internal Revenue Service
Form
(Rev. 8-2006)
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