Form 14417-A Statistics of Income - User Fee

Form 14417-A
(August 2013)

Department of the Treasury - Internal Revenue Service

OMB Number
1545-2235

Statistics of Income - User Fee

Legal Terms and Conditions incorporated by reference on page 3
1. Customer name

1a. Project agreement number (IRS USE ONLY)

2. Program contact information (for all non-payment questions)
Buyer Representative

Seller - IRS Budget Office 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:
i. Street number

d. Address:
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,

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. Customer status
New customer

Prior customer

5. Requested due date
6. Description of Statistics of Income (SOI) products for sale (use separate Statistics of Income User Fee Form for each product requested)
a. Individual Public-Use Microdata Files - Yearly files are available on CD-ROM from the SOI Division. These microdata files have
been edited to protect the confidentiality of individual taxpayers.
Year(s) requested
b. Other data requests (specify data request if not available above)

Additional requirements may be included for non-standard data transfers.
Catalog Number 27058A

For Paperwork Reduction Act Notice, see the Instructions for Form 14417

Form 14417-A (8-2013)

Page 2 of 5
7. Advance payment requirements
All entities must provide an advance payment before the IRS begins any work for the full costs of goods and/or services
ordered.
a. Total cost of products requested
8. Billing and collection contact information and payment requirements
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

Seller (organization name)
Advancement payment info (including address)

a. Official's name

a. IRS Office name

b. Official's title

b. Telephone number

c. Billing address:
i. Street number

c. FAX number
d. Email address

ii. Street name

e. TIN/EIN

iii. City
iv. State
v. ZIP code

Make advance payments to:
Internal Revenue Service
Beckley Finance Center
P.O. Box 9002
Beckley, WV 25802-9002

d. Telephone number
e. FAX number
f. Email address
g. TIN/EIN
h. DUNS
Payment method:
Paper check

Electronic check via Pay.gov

Money order

Other

9. Authorizing/Approving official information
Buyer (organization name)
a. Official's name

Seller (organization name)
a. Official's name

b. Official's title

b. Official's title

c. Telephone number

c. Telephone number

d. Email address

d. Email address

e. Signature/Date

e. Signature/Date

9a. 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.

Catalog Number 27058A

www.irs.gov

Form 14417-A (8-2013)

Page 3 of 5

Legal Terms and Conditions
1. 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.
2. 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.
3. Data Recordkeeping: The IRS reserves the right to use a copy of all data provided under this agreement.
4. Cancellations: Either the 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.
5. 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.
6. Agreement Reference: All communications between parties must refer to the Agreement by the “Project Agreement Number”
(e.g. RA20XXBXXX).

Additional Clauses
1. The Buyer is acquiring these data to be used for research, analysis and consulting. No attempt will be made to identify any
individuals on the file.
2. The data are intended to be used for research, analysis and consulting at Buyer's organization only.
3. The Buyer agrees not to provide any of these data to anyone outside of the Buyer's organization. Those who wish to have these data
will be advised to acquire it from the IRS. The prohibition on distribution of copies of this data file does not expire with this agreement.
This prohibition does not preclude the presentation of summary tabulations or other research results based on this data.
4. All Buyer's consulting or advertising material for services or products based primarily on the data provided by the IRS in the Public
Use Tax File must include the following statement. The statement is “The Internal Revenue Service (IRS) does not endorse or verify the
accuracy of products or services provided by this company. No individual taxpayer data has been provided to this company by the IRS.”
The statement must be listed in all advertising, solicitation and informational materials in bold typeface and font size no smaller than the
body of text in the material.
5. The rights of each party under this Agreement are personal to that party and may not be assigned or transferred to any other person,
firm, corporation, or other entity without the prior, express, and written consent of the other party.
6. This Agreement shall constitute the entire agreement between the Buyer and IRS and any prior understanding or representation of
any kind preceding the date of this Agreement shall not be binding upon either party except to the extent incorporated in this
Agreement.
7. Any modification of this Agreement or additional obligation assumed by either party in connection with this Agreement shall be
binding only if placed in writing and signed by each party or an authorized representative of each party.
8. The IRS will not provide the files until the Buyer's TIN/SSN clears.
9. The IRS reserves the right to cancel this agreement if the Buyer has previously or as a result of this agreement implied in advertising
or other communications that it has direct access to individualized taxpayer returns or that it has privileged access to IRS data.

Catalog Number 27058A

www.irs.gov

Form 14417-A (8-2013)

Page 4 of 5

Instructions for Form 14417-A, Statistics of Income - User Fee
Note: All information must be typed into the Statistics of Income - User Fee (Form 14417-A) other than Authorizing/Approving Officials'
Signatures.
Field
Number

Field Name

Field Action

1.

Customer name

Enter the customer name

1.a.

Project agreement number

Project agreement number (IRS USE ONLY)

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 Coordinator

2.a.

Official's name

Enter the name of the IRS Budget Office 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 Coordinator official.

2.c.

IRS Business Unit name

Enter the IRS Business Unit Name.

2.d.

Address

Enter the the address - street number, street name, city, state, and zip code of the IRS Budget Office
Coordinator official.

2.e.

Telephone number

Enter the telephone number of the IRS Budget Office Coordinator official related to the reimbursable
agreement.

2.f.

Fax number

Enter the fax number of the IRS Budget Office Coordinator official related to the reimbursable agreement.

2.g.

Email address

Enter the email address of the IRS Budget Office 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.

Customer status

Check whether you are a new or prior customer.

5.

Requested due date

Enter the due date for your order. Use the (MM-DD-YYYY) format.

6.

Description of Statistics of Income (SOI)
products for sale

Check the box by the Statistics of Income (SOI) product(s) that you are ordering. Use separate Statistics
of Income User Fee Form for each product requested.

6.a.

Year(s) requested

Enter the year(s) that you are requesting.

6.b.

Other data requests

Enter the specify data request if not available.

7.

Advance payment requirements

7.a.

Total cost of products requested

Catalog Number 27058A

Enter the total cost of the products that you requested.

www.irs.gov

Form 14417-A (8-2013)

Page 5 of 5
Field
Number
8

Field Name

Field Action

Billing & collection contact information
and payment requirements
Finance Office Representative

8.a.

Official's name

Enter the name of the Buyer's Finance Office Representative official.

8.b.

Official's title

Enter the title of the Buyer's Finance Office Representative official.

8.c.

Billing address

Enter the address - street number, street name, city, state, and zip code of the Buyer's Finance Office
Representative official.

8.d.

Telephone number

Enter the telephone number of the Buyer's Finance Office Representative official for correspondence on
billing and collection issues.

8.e.

Fax number

Enter the fax number of the Buyer's Finance Office Representative official for correspondence on billing
and collection issues.

8.f.

Email address

Enter the email address of the Buyer's Finance Office Representative official for correspondence on
billing and collection issues.

8.g.

TIN/EIN

Enter the valid Taxpayer Identification Number (TIN) or Employee Identification Number (EIN) of the
Buyer.

8.h.

DUNS

Enter the Dun and Bradstreet Universal Numbering System (DUNS) of the Buyer.

Seller - Advancement payment info
8.a.

IRS Office name

Enter the IRS Finance Office Representative official name.

8.b.

Telephone number

Enter the IRS Finance Office Representative official telephone number.

8.c.

Fax number

Enter the IRS Finance Office Representative official fax number.

8.d.

Email address

Enter the IRS Finance Office Representative official email address.

8.e.

TIN/EIN

Enter the 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.

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.

9.

Buyer
9.a.

Official's name

Enter the name of the Buyer's Authorizing/Approving official.

9.b.

Official's title

Enter the title of the Buyer's Authorizing/Approving official.

9.c.

Telephone number

Enter the telephone number of the Buyer's Authorizing/Approving official.

9.d.

Email address

Enter the email address of the Buyer's Authorizing/Approving official.

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.

9.e.

Seller
9.a.

Official's name

Enter the name of the IRS Authorizing/Approving official. Must be an IRS Employee.

9.b.

Official's title

Enter the title of the IRS Authorizing/Approving official.

9.c.

Telephone number

Enter the telephone number of the IRS Authorizing/Approving official.

9.d.

Email address

Enter the email address of the IRS Authorizing/Approving official.

9.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.

9a.

Co-Signature for authorizing/approving
official (as appropriate)

Includes additional Buyer Authorizing/Approving information fields for cases where a program area
requires multiple authorizing/approving officials.

Catalog Number 27058A

www.irs.gov

Form 14417-A (8-2013)