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Missouri Department of Revenue
Form
Champion for Children Tax Credit
MO-CIC
Name of Taxpayer
Spouse (If Applicable)
Social Security, Federal Employer I.D., or Missouri Tax I.D. Number
Spouse Social Security, Federal Employer I.D., or Missouri Tax I.D. Number
Taxpayer Address
City
State
Zip Code
Agency Name
Address
City
State
Zip Code
The above taxpayer has made the following contributions:
r
CASA (Court Appointed Special
Contribution Amount
Date
Tax Credit (50%)
Advocate)
(minimum amount $100)
r
Child Advocacy Centers
___ ___ / ___ ___ / ___ ___ ___ ___
r
Crisis Care Centers
___ ___ / ___ ___ / ___ ___ ___ ___
___ ___ / ___ ___ / ___ ___ ___ ___
r
Individual
___ ___ / ___ ___ / ___ ___ ___ ___
r
Corporation
___ ___ / ___ ___ / ___ ___ ___ ___
r
Other ___________________________
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The current tax period begins
and ends
. We are submitting this claim
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___ ___ / ___ ___ / ___ ___ ___ ___
for the purpose of establishing the taxpayer’s eligibility for the tax credit pursuant to Section 135.341, RSMo, and said taxpayer is
entitled to a tax credit of 50% of the contribution. Champion for Children tax credits are subject to available funding. If claims
exceed the funding, the redemption of the credit will be prorated to the extent funds are available.
I certify this claim to be true and accurate.
Signature of Qualified Agency Director
Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.
Signature of Taxpayer
Signature of Spouse (If Applicable)
Printed Name of Taxpayer
Printed Name of Spouse (If Applicable)
E-mail Address
Form MO-CIC (Revised 06-2013)
Mail to:
Taxation Division
Phone: (573) 526-8733
Visit
P.O. Box 27
Fax: (573) 751-7744
for additional information.
E-mail: income@dor.mo.gov
Jefferson City, MO 65105-0027