Fillable F14417 Form 14417 (Rev. 2-2013)

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F14417 Form 14417 (Rev. 2-2013)

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  • 14 check-boxes
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Form 14417 (Rev. 2-2013)
Catalog Number 59893X www.irs.gov
Department of the Treasury - Internal Revenue Service
Form 14417
(February 2013)
Reimbursable Agreement - Non-Federal Entities
(State and Local Governments, Foreign Governments,
Commercial Organizations, and Private Businesses)
OMB Number
1545-2235
Legal Terms and Conditions incorporated by reference on pages 3 and 4
1a. IRS agreement tracking number (RA+ fiscal Year + B + project number) 1b. IRS unique customer number
2. Program contact information (for all inquires other than those related to advance payment)
Buyer Representative
a. Official's name
b. Official's title
c. Organization name
d. Address:
i. Street number
ii. Street name
iii. City
iv. State
v. ZIP code
e. Telephone number
f. FAX number
g. Email address
Seller - IRS Budget Office Reimbursables Coordinator
a. Official's name
b. Official's title
c. IRS Business Unit name
d. Address:
i. Street number
ii. Street name
iii. City
iv. State
v. ZIP code
e. Telephone number
f. FAX number
g. Email address
3. Statutory authority
Internal Revenue Code (Sections 6103(p)(2), 6108(b), 6103(p)(4), 7213,
7213A, 7431) addresses authority to enter into reimbursable agreements,
safeguarding and protection of tax return information, among other provisions
impacting funds in reimbursable. See also the Legal Terms and Conditions,
Section 1 on page 3 of this form.
Other Statutory Authority superseding and/or providing more specific authority
than the IRC. For example, the Foreign Assistance Act of 1961 (22 U.S.C. 2357)
provides more specific authority and requirements for reimbursable agreements
with foreign non-federal entities.
4. Agreement action
New
Amendment (increase or decrease)
Increase
Decrease
Cancellation
5. Agreement period of performance
a. Start date
MM-DD-YYYY
b. End date
MM-DD-YYYY
c. Cancellation date
MM-DD-YYYY
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.
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)
✖
Form 14417 (Rev. 2-2013)
Catalog Number 59893X www.irs.gov
Page 2 of 6
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 direct costs (A x B) $
Indirect/Overhead costs $
Total estimated costs $
Initial reimbursable agreement amount (including any prior amendments) $
Current amendment - increase (decrease) $
Total current reimbursable agreement amount $
Total estimated costs at left must agree with the
Total current reimbursable agreement amount
below.
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 (organization name)
Finance Office Representative
a. Official's name
b. Official's title
c. Billing address:
i. Street number
ii. Street name
iii. City
iv. State
v. ZIP code
d. Telephone number
e. FAX number
f. Email address
g. TIN/EIN
h. DUNS
Seller (organization name)
Government Payables and Receivable Section (GPRS) (Advance
Payment Inquiries Only)
a. IRS Office name
d. Email address
c. FAX number
b. Telephone number
e. TIN/EIN
Make advance payments to:
Internal Revenue Service
Beckley Finance Center
P.O. Box 9002
Beckley, WV 25802-9002
Payment method:
Paper check Electronic check via Pay.gov Money order
Other
Form 14417 (Rev. 2-2013)
Catalog Number 59893X www.irs.gov
Page 3 of 6
10. CFO authorizing/approving official information
Seller (organization name)
a. Official's name
b. Official's title
c. Telephone number
d. Email address
e. Signature/Date
11. Authorizing/Approving official information
Buyer (organization name)
a. Official's name
b. Official's title
c. Telephone number
d. Email address
e. Signature/Date
Seller (organization name)
a. Official's name
b. Official's title
c. Telephone number
d. Email address
e. Signature/Date
11a. Co-Signature for authorizing/approving official (as appropriate)
Buyer (organization name - optional)
a. Official's name
b. Official's title
c. Telephone number
d. Email address
e. Signature/Date
For example, a Buyer may require more than one approving official to ratify
a reimbursable agreement.
Seller (business unit name - optional)
a. Official's name
b. Official's title
c. Telephone number
d. Email address
e. Signature/Date
For example, co-signatures from approving officials in more than one
business unit may be required under statutory authorities governing
reimbursable agreements with foreign entities.
Legal Terms and Conditions
1. IRS Reimbursable Authority: The authority to perform services on a cost reimbursable basis is contained in sections 6103(p)(2)
and 6108(b) of the Internal Revenue Code (IRC). Performance of services is authorized only when consistent with the basic public
obligations of the Internal Revenue Service (IRS). If necessary to fulfill its public obligations, the IRS may modify, reject, cancel, or
terminate any part of this agreement and return the unused balance of funds advanced.
1a. Section 6103(p)(4) of the IRC provides specific requirements for Federal, state, and local organizations to safeguard Federal tax
returns and return information as a condition of receiving the information. IRS Publication 1075, Tax Information Security Guidelines for
Federal, State, and Local Agencies (OMB No. 1545-0962) provides additional guidelines.
1b. Section 7213 of the IRC makes unauthorized disclosure of a return or return information a felony punishable by a fine not to exceed
$5,000 or imprisonment of not more than 5 years, or both, together with the costs of prosecution. Section 7213A makes unauthorized
inspection of a return or return information punishable by a fine up to $1,000, or imprisonment of not more than one year, or both,
together with the costs of prosecution. Section 7431 makes persons who knowingly or negligently make an unauthorized disclosure of a
return or return information liable for civil damages.
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Form 14417 (Rev. 2-2013)
Catalog Number 59893X www.irs.gov
Page 4 of 6
Legal Terms and Conditions (continued)
2. IRS Costing: The IRS will charge for direct and indirect/overhead costs for reimbursable work. If funds advanced to the IRS are
more than the actual cost of performing the work, the difference will be returned to the Buyer. If the advance received is less than the
actual costs incurred, the Buyer agrees to pay for the additional costs incurred and an amended Form 14417 indicating the increase in
costs must be submitted along with additional funds. See OMB Business Rules for Advance Payment Policies. IRM 1.33.3, Strategic
Planning, Budgeting and Performance Management Process; Reimbursable Operating Guidelines contains the IRS regulations
applicable to costing its reimbursable agreements.
3. Work Delays and Errors: Although the IRS will make every reasonable effort to avoid delays and errors in the performance of this
agreement, the IRS is not responsible for the Buyer’s costs incurred due to any such delays or errors. The Buyer must pay for the cost
of data recompilations or corrections.
4. Data Recordkeeping: The IRS reserves the right to use a copy of all data provided under this agreement.
5. Cancellations: Either the non-federal entity (Buyer) or the IRS (Seller) may cancel this agreement by giving written notice to the
other party 30 days before cancellation. Payment to the IRS shall include actual costs incurred through the cancellation date, plus any
termination costs. The IRS will exercise due diligence to prevent incurring costs after the cancellation date. However, the Buyer shall
also reimburse the IRS for unavoidable commitments up to the date the agreement would have expired. When an accepted order is
cancelled by the Buyer, the Seller is authorized to collect actual costs incurred through the cancellation date, plus any termination costs.
6. Dispute Resolution: Disputes and major differences between non-federal entities and the IRS shall be resolved in a similar manner
to the business rules set out in the Treasury Financial Manual, Volume 1, Bulletin No. 2011-04, Intragovernmental Business Rules,
dated November 8, 2010. See also: http://fms.treas.gov/tfm/vol1/11-04.pdf.
7. Agreement Reference: All communications between parties must refer to the Agreement by the “Project Agreement Number”
(e.g. RA20XXBXXX).
Instructions for Form 14417, Reimbursable Agreement - Non-Federal Entities
(State and Local Governments, Foreign Governments, Commercial Organizations, and Private Businesses)
Note: All information must be typed into the Reimbursable Agreement (Form 14417) other than Authorizing/Approving Officials'
Signatures.
Field
Number
Field Name Field Action
1.a. IRS agreement tracking number
Enter the IRS-assigned agreement tracking number (e.g. RA20XXBXXX). The numbering scheme is
made up of 4 accounting sections: RA (Reimbursable Agreement); 20XX (fiscal year); B (Alpha
Standard) and XXX (Unique IFS Internal Order Code for the project). Contact the IRS/ Chief Financial
Officer/Corporate Budget to establish new agreement tracking numbers. For agreements recurring from
year-to-year, use existing agreement tracking numbers, updated to reflect the current fiscal year (e.g.
RA2011B001 to RA2012B001).
1.b. IRS unique customer number
Enter the IRS-established unique customer number for the non-federal entity. The IRS Beckley Finance
Center will provide new customer numbers once a signed agreement is received. For non-federal
agreements that recur from year-to-year, IRS Business Unit Reimbursable Coordinators and Project
Coordinators should continue to use the same customer numbers.
2. Program contact information
Buyer Representative
2.a. Official's name Enter the name of the Buyer's Program Representative official.
2.b. Official's title Enter the title of the Buyer's Program Representative official.
2.c. Organization name Enter the Buyer's Organization name.
2.d. Address
Enter the address - street number, street name, city, state, and zip code of the Buyer's Program
Representative official.
2.e. Telephone number
Enter the telephone number of the Buyer's Program Representative official related to the reimbursable
agreement.
2.f. Fax number
Enter the fax number of the Buyer's Program Representative official related to the reimbursable
agreement.
2.g. Email address
Enter the email address of the Buyer's Program Representative official related to the reimbursable
agreement.
Seller - IRS Budget Office
Reimbursables Coordinator
2.a. Official's name
Enter the name of the IRS Budget Office Reimbursables Coordinator official who will be certifying that
advance payment(s) have been received, confirming work completion, and product delivery and/or
services being rendered.
2.b. Official's title Enter the title of the IRS Budget Office Reimbursables Coordinator official.
Form 14417 (Rev. 2-2013)
Catalog Number 59893X www.irs.gov
Page 5 of 6
Field
Number
Field Name Field Action
2.c. IRS Business Unit name Enter IRS Business Unit Name.
2.d. Address
Enter the address - street number, street name, city, state, and zip code of the IRS Budget Office
Reimbursables Coordinator official.
2.e. Telephone number
Enter the telephone number of the IRS Budget Office Reimbursables Coordinator official related to the
reimbursable agreement.
2.f. Fax number
Enter the fax number of the IRS Budget Office Reimbursables Coordinator official related to the
reimbursable agreement.
2.g. Email address
Enter the email address of the IRS Budget Office Reimbursables Coordinator official related to the
reimbursable agreement.
3. Statutory authority
Internal Revenue Code section references box is pre-populated. These statutory references always
apply. Other Statutory Authority - This box should be checked when an additional statutory authority
applies. Enter additional statutory authority on the line provided, if applicable.
4. Agreement action
Enter agreement-related action type. (e.g., New, Amendment, or Cancellation)
1) Either New or Amendment must be checked.
2) If Amendment is checked, then either Increase, Decrease or Cancellation must be checked.
5. Agreement period of performance
Enter the following information:
1) The start date of the agreement (effective date)
2) The end date of the agreement (the estimated completion date for support under this
agreement). Note: IRS agreements operate on a fiscal year basis. Funding received from state,
local and foreign governments applies to the current fiscal year only. Multi-year funding cannot be
retained or applied to future fiscal years.
3) Enter the cancellation date of the agreement, if applicable.
6.
Description of requested products and/or
services to be provided
Enter a description of requested products and/or services to be provided by the IRS, including scope of
work or work statement to support delivery orders.
7. Advance payment requirements
Non-federal customers must provide an advance payment before the IRS begins any work for the
full cost of goods and/or services to be provided.
Indicate the type of draw down method to be used: One box must be checked which denotes the
frequency of revenue recognition and frequency of the advance draw down. "Monthly" is the
recommended drawn down frequency.
Breakdown of reimbursable cost
estimate
Unit of measure applicable to project Indicate the unit of measure that will be used to cost the project.
Item quantity (A) Enter the number of items, hours, or other unit of measure related to the project, as applicable.
Unit price (B) Enter the unit price of the product being delivered or services being rendered, as applicable.
Total direct costs (A X B) Enter total direct costs. See IRM 1.33.8 Reimbursable Operating Guidelines - Costing.
Indirect/Overhead costs
Enter the total indirect/overhead costs. Examples of indirect/overhead Costs include: a) General
management and administrative services, b) Facilities management and ground maintenance services
(security, rent, utilities, and building maintenance), c) Procurement and contracting services, d) Financial
management and accounting services, e) Information technology services, f) Services to acquire and
operate property, plant and equipment, g) Publication, reproduction, graphics and video services,
h) Research, analytical, and statistical services, i) Human resources/personnel services, and j) Library
and legal services. See IRM 1.33.8 Reimbursable Operating Guidelines - Costing.
Total estimated costs Enter the total amount of estimated costs which equals direct and indirect/overhead costs.
Initial reimbursable agreement amount,
including any prior amendments
Enter the initial reimbursable agreement amount or the initial reimbursable agreement amount amount
adjusted for any increases or decreases before the most recent amendment.
Current amendment - increase
(decrease) Enter the current amendment amount - increase (decrease), as applicable.
8.
Total current reimbursable agreement
amount
Enter the summation of the Initial Reimbursable Agreement Amount, including any prior amendments
and Current Amendment - increase (decrease) fields.
9.
Billing & collection contact information
and payment requirements
Finance Office Representative
9.a. Official's name Enter the name of the Buyer's Finance Office Representative official.
9.b. Official's title Enter the title of the Buyer's Finance Office Representative official.
9.c. Billing address
Enter the address - street number, street name, city, state, and zip code of the Buyer's Finance Office
Representative official.
9.d. Telephone number
Enter the telephone number of the Buyer's Finance Office Representative official for correspondence on
billing and collection issues.
9.e. Fax number
Enter the fax number of the Buyer's Finance Office Representative official for correspondence on billing
and collection issues.
9.f. Email address
Enter the email address of the Buyer's Finance Office Representative official for correspondence on
billing and collection issues.
Form 14417 (Rev. 2-2013)
Catalog Number 59893X www.irs.gov
Page 6 of 6
Field
Number
Field Name Field Action
9.g. TIN/EIN
Enter the valid Taxpayer Identification Number (TIN) or Employee Identification Number (EIN) of the
Buyer.
9.h. DUNS Enter the Dun and Bradstreet Universal Numbering System (DUNS) of the Buyer.
Seller - Government Payables and
Receivable Section
9.a. IRS Office name Pre-populated with BFC GPRS Helpdesk.
9.b. Telephone number Pre-populated with BFC GPRS Helpdesk telephone number.
9.c. Fax number Pre-populated with BFC GPRS Helpdesk fax number.
9.d. Email address Pre-populated with BFC GPRS Helpdesk email address.
9.e. TIN/EIN Pre-populated with IRS Taxpayer Identification Number (TIN).
Payment method
Enter payment method option: 1) Paper Check, 2) Electronic Check via Pay.gov, 3) Money Order, or
4) Other. If another method is selected, describe the method used. One box must be checked.
10.
CFO authorizing/approving official
information
Seller
10.a. Official's name Enter the name of the Director, Budget Execution.
10.b. Official's title Enter Director, Budget Execution.
10.c. Telephone number Enter the telephone number of the Director, Budget Execution.
10.d. Email address Enter the email address of the Director, Budget Execution.
10.e. Signature/Date
The Director, Budget Execution must sign and date to authorize the funding of products and/or services
provided to the buyer on behalf of the seller. Work on the project Work on the project will not begin until
the sign-off has occurred.
11. Authorizing/Approving official information
Note: Section 11a includes additional Buyer and Seller Authorizing/Approving information fields for cases
where a program area requires multiple authorizing/approving officials.
Buyer
11.a. Official's name Enter the name of the Buyer's Authorizing/Approving official.
11.b. Official's title Enter the title of the Buyer's Authorizing/Approving official.
11.c. Telephone number Enter the telephone number of the Buyer's Authorizing/Approving official.
11.d. Email address Enter the email address of the Buyer's Authorizing/Approving official.
11.e. Signature/Date
The Buyer's Authorizing/Approving Official must sign and date to authorize the purchase of products and/
or services provided on behalf of the requesting entity. Work on the project cannot begin until final
signatures have been obtained.
Seller
11.a. Official's name Enter the name of the IRS Authorizing/Approving official. Must be an IRS Employee.
11.b. Official's title Enter the title of the IRS Authorizing/Approving official.
11.c. Telephone number Enter the telephone number of the IRS Authorizing/Approving official.
11.d. Email address Enter the email address of the IRS Authorizing/Approving official.
11.e. Signature/Date
The IRS Authorizing/Approving Official must sign and date to authorize the funding of products and/or
services provided to the buyer on behalf of the seller. Work on the project will not begin until the sign-off
has occurred.
11a.
Co-Signature for authorizing/approving
official (as appropriate)
Includes additional Buyer and Seller Authorizing/Approving information fields for cases where a program
area requires multiple authorizing/approving officials.
Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. You are required
to give us the information. We need it to ensure that you are complying with these laws.
You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB
control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the
administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by section 6103.
The time needed to complete and file this form will vary depending on individual circumstances. The estimated burden for filing this form is approved
under OMB control number 1545-2235. The estimated burden is shown below.
Recordkeeping . . . . . . . . . . 0.
Learning about the law or the form . . . . . . . . . . . . 10 min.
Preparing and sending the form to the IRS . . . . . . . . . 20 min.
If you have comments concerning the accuracy of these time estimates or suggestions for making this form simpler, we would be happy to hear from
you. See the instructions above.
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F14417 Form 14417 (Rev. 2-2013)

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Completed 7 April 2020

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