Certificate Of Contribution For Tax Credit Form printable pdf download

Certificate Of Contribution For Tax Credit Form

Tennessee Department of Revenue

Rural Opportunity Fund

CERTIFICATE OF CONTRIBUTION FOR TAX CREDIT

PART 1 - BUSINESS AND CONTRIBUTION INFORMATION (Completed by Contributor)

Name of financial institution: __________________________________________________________________

Business mailing address: ____________________________________________________________________

Contact person and title: __________________________________ Telephone number: ( ___ ) ____________

Tennessee Franchise and Excise number: ____________________________________________

Tax Year (Check One)

Calendar year

Fiscal year from _______ to _________

Qualified Contribution $ ____________

Date Approved

_______________

Submitted by: __________________________________________

Name of Financial Institution

By: __________________________

____________________________________

_________________

Signature

Print Name and Title

Date

PART 2 - SOUTHEAST COMMUNITY CAPITAL CERTIFICATION (Completed by SCC)

Amount of Eligible Contribution: _________________________

Approved By: __________________________

_________________________________

____________

Signature

Print Name and Title

Date

PART 3 - DEPARTMENT OF REVENUE CERTIFICATION (Completed by Revenue)

Annual Amount of Tax Credit: ___________________________

Approved By: __________________________

_________________________________

____________

Signature

Print Name and Title

Date

RV-F1319401

Certificate Of Contribution For Tax Credit Form