0418 Form 13424 (PDF)

Official source: IRS Forms, Instructions & Publications (https://www.irs.gov/pub/irs-pdf/f13424.pdf), retrieved 2026-10-03. U.S. Government work (17 U.S.C. § 105).

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(April 2018)

OMB Number

1545-1648

Grant Period Request (Check one)

New application

Non-Competitive continuation

Department of the Treasury - Internal Revenue Service

Single year Multi-year

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

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

Street

City State ZIP + 4 code

Clinic Director Information

Clinic Mailing Address

Street

City State ZIP + 4 code

Prefix Last name First name Middle initial Suffix

Telephone number Email address

Licenses/Certifications (Check all that apply)

Attorney CPA Enrolled Agent Other

Catalog Number 36126D www.irs.gov Form 13424 (Rev. 4-2018)

Page 2

Qualified Tax Expert (QTE)

Prefix Last name First name Middle initial Suffix

Telephone number Email address

Licenses/Certifications (Check all that apply)

Attorney CPA Enrolled Agent Other

Qualified Business Administrator (QBA)

Prefix Last name First name Middle initial Suffix

Telephone number Email address

Tax Compliance Officer

Prefix Last name First name Middle initial Suffix

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)

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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)