0515 Form 9368 (PDF)

Official source: IRS Forms, Instructions & Publications (https://www.irs.gov/pub/irs-pdf/f9368.pdf), retrieved 2026-10-03. U.S. Government work (17 U.S.C. § 105).

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(May 2015)

Department of the Treasury - Internal Revenue Service

Taxpayer's name and address In reply refer to:

Tax year

Last four digits of Social Security Number

To assist us in the examination of your return, please review all of the following questions. If not applicable, enter "N/A." Also, please provide a copy of the grant you received, and your application for it.

1. What was the amount of the grant

$

2. What is the name of the organization or institution that awarded the grant

3. Did you receive any amounts in addition to the grant Yes No

If Yes, please complete the following:

a. Amount for travel

$

b. Amount for materials and supplies

$

c. Other amounts

$

Other amounts (Specify)

4a. The grant was awarded under the terms of a contract between the institution and the U. S. Government Yes No

4b. The grant was awarded under the terms of a contract between the institution and a private organization Yes No

5. What period of time was the grant for Beginning (MM/DD/YYYY) Ending (MM/DD/YYYY)

6. Who was the grant awarded to a. directly to you b. the school or institution c. the head of your department

7. Were you free to choose your field and location of research Yes No

If Yes, explain

8. If you performed duties other than research, what was the approximate percentage of time you spent on:

a. Examining patients % b. Teaching % c. Lecturing % d. Other %

Other (Specify)

9. Were you provided any of the following:

a. Sick Leave b. Vacations c. Insurance d. Other fringe benefits

Other fringe benefits (Specify)

10. To whom were progress reports, if required, furnished

11. Were you entitled to any copyrights or patents that resulted from your work Yes No

If No, who was entitled to them

12a. Have you worked for the grantor in the past Yes No

If Yes, explain

12b. Will you work for the grantor in the future Yes No

If Yes, explain

13. How many months, if any, have you previously excluded income from a grant

14. Were you on a leave of absence from another position Yes No

If Yes, please furnish a statement from that employer showing dates of employment, length of leave, and expected date of return.

Certification: Under penalties of perjury, I declare that I have examined this statement and, to the best of my knowledge and belief, it is true, correct, and complete.

Taxpayer's signature SIGN Date

Catalog Number 13346B www.irs.gov Form 9368 (Rev. 5-2015)