Form 13424 - Low Income Taxpayer Clinic (Litc) Application Information

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Department of the Treasury - Internal Revenue Service
13424
OMB Number
Form
Low Income Taxpayer Clinic (LITC)
1545-1648
(April 2016)
Application Information
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
Title
Phone number
FAX number
Email address
Applicant's Mailing Address
Street
Street address line 2
City
State
ZIP + 4 code
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
Clinic Director Information
Prefix
Last name
First name
Middle initial
Suffix
Telephone number
Email address
Licenses/Certifications (Check all that apply)
Attorney
CPA
Enrolled Agent
Other
13424
Form
(Rev. 4-2016)
Catalog Number 36126D

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