Form Dr-116000 - Application For Tax Credit Allocation For Contributions To Nonprofit Sfos

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DR-116000
R. 07/12
Application for Tax Credit Allocation for Contributions to
Nonprofit Scholarship Funding Organizations (SFOs)
Rule 12-29.003
Florida Administrative Code
(Under sections [ss.] 211.0251, 212.1831, 220.1875, 561.1211, 624.51055,
Effective 01/13
and 1002.395, Florida Statutes, [F.S.])
Business name ___________________________________________________________________________________________
Federal Employer Identification Number (FEIN)
Mailing address __________________________________________________________________________________________
City ___________________________________________ State _____________ ZIP __________________________________
Contact person ___________________________ Contact’s telephone number ____________________________________
Choose one of the two options below. You must complete a separate application for each nonprofit SFO and for each
separate beverage license for which a separate return is filed. For credit carry forward purposes, a separate application
for each nonprofit SFO is not required.
1. _______ Contribution to nonprofit SFO
Enter the name of the Department of Education approved nonprofit SFO you are planning to contribute
to: _______________________________________________________________________________________________
2. _______ Credit Carry Forward
Total amount of planned contribution or credit carry forward: $ _________________________________________
Amount to be credited against each tax (The sum of the amounts by tax cannot exceed the total planned contribution
or credit carry forward above.):
______________ Corporate Income Tax (Chapter 220, F.S.)
Beginning Date of Tax Year: ___________
Ending Date of Tax Year: ___________
______________ Insurance Premium Tax (s. 624.509, F.S.)
(For the current Calendar Year)
______________ Excise Tax on Malt Beverages (s. 563.05, F.S.)
For the Fiscal Year beginning July 1, _____________and ending June 30, ____________
Please provide your Malt Beverage License Number: ___________________________________
______________ Excise Tax on Wine Beverages (s. 564.06, F.S.)
For the Fiscal Year beginning July 1, _____________and ending June 30, ____________
Please provide your Wine Beverage License Number: ___________________________________
______________ Excise Tax on Liquor Beverages (s. 565.12, F.S.)
For the Fiscal Year beginning July 1, _____________and ending June 30, ____________
Please provide your Liquor Beverage License Number: __________________________________
______________ Sales and Use Tax due from a Direct Pay Permit Holder (s. 212.183, F.S.)
For the Fiscal Year beginning July 1, _____________and ending June 30, ____________
Direct pay permit holders must provide their sales tax certificate number below:
Sales Tax Certificate Number
______________ Tax on Oil Production (s. 211.02, F.S.)
For the Fiscal Year beginning July 1, _____________and ending June 30, ____________
______________ Tax on Gas Production (s. 211.025, F.S.)
For the Fiscal Year beginning July 1, _____________and ending June 30, ____________
If you file a consolidated Florida corporate income tax return, you must provide the parent corporation’s name and FEIN.
Parent corporation ________________________________________________________________________________________
Parent corporation’s FEIN
Under penalty of perjury, I declare that I have read this application form and that the facts stated in it are true.
________________________________________________
______________________
Signature of officer, owner, or partner
Date

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