Form 14417 - Reimbursable Agreement - Non-Federal Entities (State And Local Governments, Foreign Governments, Commercial Organizations, And Private Businesses) Page 2

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7. Advance payment requirements
All non-federal entities must provide an advance payment before the IRS begins any work for the full costs of goods and/or
services ordered.
For IRS Use Only: Once work has been completed and revenue earned, a commensurate amount will be drawn down against the
advance payment using one of the following draw-down options.
Monthly
Quarterly
Lump-Sum/One-Time - Products and/or services may be provided once or
multiple times, however the full amount of earnings are recognized the first
time a product is delivered and/or a service is rendered.
8. Breakdown of reimbursable cost estimate
Unit of measure applicable to project
Item quantity (A)
Unit price (B)
$
Total estimated costs at left must agree with the
Total direct costs (A x B) $
Total current reimbursable agreement amount
below.
Indirect/Overhead costs $
Total estimated costs $
Initial reimbursable agreement amount
$
(including any prior amendments)
Current amendment - increase (decrease)
$
Total current reimbursable agreement amount
$
9. Billing and collection contact information and payment requirements
Non-Federal Entities must provide a valid Taxpayer Identification Number (TIN) or Employee Identification Number (EIN). The Dun and
Bradstreet Universal Numbering System (DUNS) is the vendor data network used by the IRS. Insert TIN/EIN and DUNS numbers
below. Submit advance payment to the mailing address referenced below.
Buyer
Seller
(organization name)
(organization name)
Government Payables and Receivable Section (GPRS)
(Advance
Finance Office Representative
Payment Inquiries Only)
a. Official's name
a. IRS Office name
b. Telephone number
b. Official's title
c. FAX number
c. Billing address:
d. Email address
i. Street number
e. TIN/EIN
ii. Street name
iii. City
iv. State
Make advance payments to:
v. ZIP code
Internal Revenue Service
d. Telephone number
Beckley Finance Center
e. FAX number
P.O. Box 9002
Beckley, WV 25802-9002
f. Email address
g. TIN/EIN
h. DUNS
Payment method:
Paper check
Electronic check via Pay.gov
Money order
Other
14417
Form
(Rev. 2-2013)
Catalog Number 59893X

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