25-LITCApplication.docx

Application Fiscal Year: ______________ Grant Amount Requested (This amount is from the proposed budget) Clinic/Applicant Information

Legal Name of LITC Organization (Applicant) Telephone Number Email Address

Filing Tax Identification number (EFIN/TIN) Website Address

Name of contact person/contract manager Direct Telephone Number: Contact email address:

Contract Number (if applicable)

Under the pains and penalties of perjury, by signing this application I certify all the following:

· The information contained in this application is true.

· I have the authority to execute this application on behalf of the Applicant.

· The Applicant is registered with DOR and the Secretary of the Commonwealth of Massachusetts.

· The Applicant accepts the terms of the LITC Grant Application and Grant Agreement without substantive changes.

· The Applicant is in stable financial condition and has not been in bankruptcy and/or receivership within the last three calendar years.

· The Applicant is compliant with all Massachusetts tax and child support laws, and requirements of wage withholding and reporting.

· The Applicant will disclose any civil litigation, criminal investigation, indictment, prosecution, or other proceeding that has been brought against Applicant in the last three years.

· The Applicant will disclose any potential conflicts of interest, including any possible conflicts of interest the applicant’s employees may have, in connection with the performance of services required under the Grant Agreement resulting from this Grant Agreement.

Signature

Signature of applicant or Director

Date

Print applicant’s or Director’s name

Title

Required documents for COMMBUYS*:

· Copy of IRS Award Letter for current program period if applicable

· Commonwealth Standard Contract Form (Includes the Commonwealth Terms and Conditions)

· Request for Taxpayer Identification Number and Certification (Massachusetts Substitute W-9 Form)**

· Contractor Authorized Signatory Listing**

· Electronic Funds Transfer Sign Up Form**

· Program Plan includes (history/capacity of clinic, how funds will be used to expend services, etc.)

· Program Budget with Narrative for requested Amount*

*If the LITC is already under contract, it must submit this application and the Program budget for the Fiscal Year to DOR directly to taxadvocate@dor.state.ma.us. It does not need to submit a bid on COMMBUYS.

**Please contact the Grant Application Contact for the form. These forms may not be required if previously submitted.

image1.png image2.png