Form 14417 - Reimbursable Agreement - Non-Federal Entities

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Department of the Treasury - Internal Revenue Service
14417
Reimbursable Agreement - Non-Federal Entities
OMB Number
Form
1545-2235
(State and Local Governments, Foreign Governments,
(February 2013)
Commercial Organizations, and Private Businesses)
Legal Terms and Conditions incorporated by reference on pages 3 and 4
1a. IRS agreement tracking number
1b. IRS unique customer number
(RA+ fiscal Year + B + project number)
2. Program contact information
(for all inquires other than those related to advance payment)
Buyer Representative
Seller - IRS Budget Office Reimbursables Coordinator
a. Official's name
a. Official's name
b. Official's title
b. Official's title
c. Organization name
c. IRS Business Unit name
d. Address:
d. Address:
i. Street number
i. Street number
ii. Street name
ii. Street name
iii. City
iii. City
iv. State
iv. State
v. ZIP code
v. ZIP code
e. Telephone number
e. Telephone number
f. FAX number
f. FAX number
g. Email address
g. Email address
3. Statutory authority
Internal Revenue Code (Sections 6103(p)(2), 6108(b), 6103(p)(4), 7213,
Other Statutory Authority superseding and/or providing more specific authority
7213A, 7431) addresses authority to enter into reimbursable agreements,
than the IRC. For example, the Foreign Assistance Act of 1961 (22 U.S.C. 2357)
safeguarding and protection of tax return information, among other provisions
provides more specific authority and requirements for reimbursable agreements
impacting funds in reimbursable. See also the Legal Terms and Conditions,
with foreign non-federal entities.
Section 1 on page 3 of this form.
4. Agreement action
Increase
New
Amendment (increase or decrease)
Cancellation
Decrease
5. Agreement period of performance
a. Start date
MM-DD-YYYY
b. End date
Note: Enter the estimated completion (End) date for support under this agreement.
IRS agreements operate on a fiscal year basis and do not cross fiscal years.
MM-DD-YYYY
c. Cancellation date
MM-DD-YYYY
6. Description of requested products and/or services to be provided
(state or attach a description of products/services, including the bona fide
need for this service)
14417
Form
(Rev. 2-2013)
Catalog Number 59893X

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