Form 13424-I - Low Income Taxpayer Clinic (Litc) Litc Tax Information Authorization
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1Low Income Taxpayer Clinic (LITC)
OMB Number
LITC Tax Information Authorization
1545-1648
As provided for in Publication 3319, all applicants for an LITC grant must be in compliance with Federal tax responsibilities. The LITC
Program Office will conduct compliance checks on organizations applying for an LITC grant and will also conduct periodic checks
throughout the grant period. Therefore, any LITC that is part of a larger organization (e.g., university) will need to have an authorized
official from the larger organization complete the following authorization:
Name of academic institution or other parent organization
Name of Low Income Taxpayer Clinic (LITC)
I authorize the Internal Revenue Service to disclose the following return information, as that term is defined in Internal Revenue Code
section 6103(b), of the Academic Institution or Parent Organization (listed above) to the Director of the Low Income Taxpayer Clinic
(listed above) in connection with the clinic’s application for a low income taxpayer clinic matching grant and continued entitlement to
such grant. Specifically, I authorize the Internal Revenue Service to disclose that the Academic Institution or Parent Organization has
an outstanding federal tax liability (amount, type of tax, and periods) that may affect the approval of the clinic’s grant application by the
Internal Revenue Service or the clinic’s continued entitlement to such grant.
I am aware that without this authorization the return information of the Academic Institution or Parent Organization is confidential and is
protected by law under the Internal Revenue Code. I certify that I am authorized by law to bind the Academic Institution or Parent
Organization and that I have authority to execute this consent to disclose return information.
Taxpayer name
Street
City
State
ZIP + 4 code
Employer Identification Number (EIN)
Name of authorized person
Title of authorized person
Telephone number
Email address of authorized person
Signature of authorized person
Date signed
13424-I
Form
(Rev. 4-2012)
Catalog Number 57683F
Department of the Treasury - Internal Revenue Service
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