Form F-1159 - Application For Child Care Tax Credits - 2003
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1F-1159
R. 01/03
Application for Child Care Tax Credits
(Under sections 220.19 or 624.5107, Florida Statutes)
For taxable year beginning ___________________,________, and ending___________________,________
❏ Joint application
Business Information
Facility Information
Business FEIN: _________________________________
Facility FEIN: ___________________________________
Business name: _________________________________
Facility name: __________________________________
Mailing address: ________________________________
Mailing address: ________________________________
City: __________________________________________
City: __________________________________________
State: ___________________ ZIP: __________________
State: ___________________ ZIP: __________________
Street address (if different): ________________________
Street address (if different): ________________________
City: __________________________________________
City: __________________________________________
State: ___________________ ZIP: __________________
State: ___________________ ZIP: __________________
Contact name: __________________________________
E-mail address: _________________________________
E-mail address: _________________________________
Phone: _________________ Fax: __________________
Phone: _________________ Fax: __________________
Child care facility license number: ___________________
(Indicate N/A if the facility is providing daily care to mildly ill
Consolidated Return Filing Information
children and not required to be licensed. Written
verification by the Department of Children and Families
Corporate name: ________________________________
or a local licensing agency must be provided in all
FEIN appearing on tax return: ______________________
cases before approval can be granted to take the
(This information may be different than the business and
credit. Please refer to the instructions.)
facility information when a consolidated Florida corporate
income tax return is filed. See instructions.)
Basis of Credit
(check those that apply)
Note: Certain contributions to a not-for-profit corporation operating a facility may also qualify for credit. See instructions.
❏ 1) Establishment of a facility (start-up costs).
$_________________ Start-up costs (Any approved credit cannot be greater than 50 percent of these costs).
❏ 2) Operation of a facility ($50 per month for each child enrolled).
Jan.
Feb.
March
April
May
June
July
Aug.
Sept.
Oct.
Nov.
Dec.
Total
No. of
Children
❏ 3) Payments made directly to facilities. (Enter the total monthly payments. Any approved credit cannot be
greater than 50 percent of such payments. Please refer to the instructions.)
Jan.
Feb.
March
April
May
June
July
Aug.
Sept.
Oct.
Nov.
Dec.
Total
No. of
Children
Monthly
Payment
I hereby certify that this application form has been examined by me and the information
Send completed form to:
contained herein is, to the best of my knowledge and belief, true, correct, and complete.
MISCELLANEOUS TAX UNIT
FLORIDA DEPARTMENT OF
REVENUE
_______________________________________________
_________________
5050 W TENNESSEE ST BLDG F-3
TALLAHASSEE FL 32399-0100
Signature of officer, owner, or partner
Date
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