Fillable Form Mo-Cfc - Champion For Children Tax Credit (Page 2 of 2) in pdf

Form Mo-Cfc - Champion For Children Tax Credit Page 2

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Additional Contributions

Contribution Amount

Date (MM/DD/YY)

Tax Credit (50%)

(Minimum amount $100)

-- Round to nearest dollar --

__ __ / __ __ / __ __ __ __

We are submitting this claim 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

Date (MM/DD/YYYY)

__ __ / __ __ / __ __ __ __

Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.

Taxpayer Signature

Taxpayer’s Printed Name

Date (MM/DD/YYYY)

__ __ / __ __ / __ __ __ __

Spouse’s Signature (if applicable)

Spouse’s Printed Name

Date (MM/DD/YYYY)

__ __ / __ __ / __ __ __ __

This form must be attached to the Miscellaneous Income Tax Credits

(Form

MO-TC), along with your tax return.

Form MO-CFC (Revised 12-2016)

Taxation Division

Phone: (573) 751-3220

Individual Income Tax

Business Tax

Fax: (573) 751-7744

P.O. Box 27

P.O. Box 3365

E-mail:

taxcredit@dor.mo.gov

Jefferson City, MO 65105-0027

Jefferson City, MO 65105-3365

Visit

for additional information.

*14301020001*

14301020001

Form Mo-Cfc - Champion For Children Tax Credit Page 2

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