Form 13424 - Low Income Taxpayer Clinics (Litcs) Application Information

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Low Income Taxpayer Clinics (LITCs)
Application Information
Grant Period Request
(Check one)
Single year request
Multi-year request
1st of 3 years
2nd of 3 years
3rd of 3 years
Grant Amount Requested for 2012
Controversy
ESL
Total
Applicant Information
Legal name of sponsoring organization
Primary contact name
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)
Website address (if applicable)
FAX number
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
Name
Telephone number
Email address
Licenses/Certifications (Check all that apply)
Attorney
CPA
Enrolled Agent
Other
Qualified Tax Expert (QTE)
Name
Telephone number
Email address
Licenses/Certifications (Check all that apply)
Attorney
CPA
Enrolled Agent
Other
Qualified Business Administrator (QBA)
Name
Telephone number
Email address
13424
Department of the Treasury-Internal Revenue Service
Form
(Rev. 5-2011)
Catalog Number 36126D

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Parent category: Financial
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