Form Cic - Children In Crisis Tax Credit
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FORM
CIC
MISSOURI DEPARTMENT OF REVENUE
CHILDREN IN CRISIS TAX CREDIT
(REV. 10-2007)
CHILDREN IN CRISIS TAX CREDIT, SECTION 135.327, RSMo
NAME OF TAXPAYER
SPOUSE (IF APPLICABLE)
SOCIAL SECURITY NUMBER, FEDERAL TAX ID NUMBER AND/OR MO STATE TAX ID NUMBER
SPOUSE ID NUMBER
ADDRESS OF TAXPAYER
CITY
STATE
ZIP CODE
QUALIFIED AGENCY NAME AND ADDRESS
AGENCY TYPE
TAX TYPE
CASA
INDIVIDUAL
CHILD ADVOCACY CENTERS
CORPORATION
CRISIS CARE CENTERS
OTHER _______________________________
THE ABOVE TAXPAYER HAS MADE THE FOLLOWING CONTRIBUTION(S):
CONTRIBUTION AMOUNT
DATE OF CONTRIBUTION
TAX CREDIT (50%)
(minimum amount $100)
The current tax period begins __________________________ and ends ______________________________ . We are submitting this claim for
the purpose of establishing the taxpayer’s eligibility for the tax credit pursuant to Section 135.327, RSMo, and said taxpayer is entitled to a tax credit
of 50% of the contribution. CIC 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 I have examined the above information, including accompanying schedules and statements, and to the best of my knowledge
and belief it is true, correct, and complete.
SIGNATURE OF TAXPAYER
SIGNATURE OF SPOUSE (IF APPLICABLE)
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