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47 Form 14204 (Rev. 3-2019) www.irs.gov Catalog Number 57258Q Form 14204 (March 2019) Department of the Treasury - Internal Revenue Service Tax Counseling for the Elderly (TCE) Program Application Checklist and Contact Sheet OMB Number 1545-2222 Contact Information Name of organization Address of organization Telephone number FAX number Point of Contact (POC) name Point of Contact (POC) title Email address for POC Administrative Information Has your organization registered or renewed your registration this year through the System for Award Management (SAM) at www.sam.gov? Yes No Is your organization interested in applying for a multi-year grant? Yes No If YES, have you checked the criteria under the Multi-Year Grant Opportunities section of Publication 1101 to determine if your organization is eligible to apply? Yes No Application Checklist and Assembly All documents requiring a signature must contain either an electronic signature or scanned copy of the original signature. Make sure you double check that you have all documents and information required. Technical ranking occurs simultaneously with the Grant Program Office (GPO) evaluation. Any missing information identified by the GPO during its evaluation may not be considered by technical evaluators depending on when the review is completed. It is the responsibility of the applicant to ensure all information is submitted. Incomplete applications meeting basic eligibility will be scored based on the information available at time of review. Therefore, it is extremely important that the submission is complete. Checklist: 1. Form 14204, TCE Application Checklist & Contact Sheet (this sheet) 2. Background Narrative 3. Nonprofit Status Determination letter issued by the Internal Revenue Service 4. Explanation on the organization’s letterhead, if Federal tax returns are not required to be file 5. Proposed Program/Budget Plan 6. Form 8653, TCE Application Plan 7. Standard Form 424, Application for Federal Assistance 8. Civil Rights Narrative 9. Form 14335, Contact Information for VITA & TCE 10. Standard Form LLL, Disclosure of Lobbying Activities (if required) Application Due Date: May 31st (Note: If May 31st falls on a weekend, the Monday following the 5/31 date will be the deadline for application submission) IRS Volunteer Income Tax Preparation and Outreach Programs Privacy and Paperwork Reduction Act Notice Privacy and Paperwork Reduction Act Notice - The Privacy Act of 1974 requires that when we ask for information we tell you our legal right to ask for the information, why we are asking for it, and how it will be used. We must also tell you what could happen if we do not receive it, and whether your response is voluntary, required to obtain a benefit, or mandatory. Our legal right to ask for information is 5 U.S.C. 301. The Paperwork Reduction Act requires that the IRS display an OMB control number on all public information requests. The OMB Control Number for this study is 1545-2222. The time estimated for participation is 10 minutes. We are asking for this information to assist us in contacting you relative to your interest and/or participation in the IRS volunteer income tax preparation and outreach programs. The information you provide may be furnished to others who coordinate activities and staffing at volunteer return preparation sites or outreach activities. The information may also be used to establish effective controls, send correspondence and recognize volunteers. Your response is voluntary. However, if you do not provide the requested information, the IRS may not be able to use your assistance in these programs. Appendix B - TCE Application Forms & Aids Exhibit 1 - Form 14204, TCE Program Application Checklist & Contact Sheet