Form Che-400 Students With Disabilities Tuition Tax Credit Verification

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-400
CHE
SOUTH CAROLINA COMMISSION ON HIGHER EDUCATION
(9/1/05)
STUDENTS WITH DISABILITIES
0000
TUITION TAX CREDIT VERIFICATION
Date: __________________
Tax Year in which you are filing: ______ (January 1 - December 31)
Part I. Taxpayer Information
Last Name: _________________________ First Name: ____________________ M.I.: ________
Social Security Number: _____-___-______
Mailing Address: _______________________________________________________________________
Phone Number: (
) _____________
Part II. Student Information
Last Name: _________________________ First Name: ____________________ M.I.: ________
Social Security Number: _____-___-______
Mailing Address: _______________________________________________________________________
Phone Number: (
) _____________
South Carolina Institution of attendance: _____________________________________________________
Part III. Disability Services Provider Verification
The Disability Services Provider at the institution of attendance must complete Part III. If the student attended more than
one institution in the tax year, a Verification Form must be completed for each institution of attendance and must be
verified by the Disability Services Provider at each institution of attendance.
Name: _____________________________
Title: ____________________________________________
Institution:______________________________________________
Office:__________________________________________________
I verify that ______________________ was certified under the Americans with Disabilities Act and Section 504 of the
Rehabilitation Act of 1973 as a student with a disability prior to each semester of enrollment (Spring, Summer, and Fall)
semesters. I have determined that this student was unable to successfully complete 30 credit hours (or credit hour
equivalents) this year. As a result, ______________________ was approved to enroll in less than 30 credit hours (or
credit hour equivalents) during the Spring, Summer, and Fall semesters.
__________________________________________
____________________
Signature, Disability Services Provider
Date
Part IV. Student / Taxpayer Verification
I hereby certify that the eligibility requirements for the Tuition Tax Credit are met in accordance with Section 2. Article 25,
Chapter 6, Title 12 of the 1976 Code. I hereby certify that the above Disability Services Provider has determined that the
credit hour requirement be reduced as a result of a documented and verified disability.
____________________________________________
______________________
Student Signature (required)
Date
____________________________________________
______________________
Parent / Legal Guardian (required)
Date
This document must be attached to the South Carolina Department of Revenue
Tuition Tax Credit Form (I-319) and submitted together with the SC1040.

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