Form 1a - Oklahoma Volunteer Firefighter Tax Credit

Form 1A

2005

Oklahoma Volunteer Firefighter Tax Credit

supporting documentation for the $200.

credit

Recognizing the importance of volunteer firefighters and

the challenges they face, Title 68 O.S. Section 2358.7

Your

provides the opportunity to receive a tax credit for fire-

Social Security

fighter training.

Number

FOR FURTHER EXPLANATIONS, see instructions on back

Section 1. Y

OUR

NFORMATION:

OR visit online OR

call 1-800-308-5336 OR (405) 424-1452

( 8 to 4 pm, weekdays)

Print first name and initial

last name

RINT

Under penalties of perjury, I declare the information

YPE

Present home address (number and street, including apartment number or rural route)

presented here is true and correct, to the best

of my knowledge and belief.

City, Sta te and Zip

In accordance with the Privacy Act, I hereby give

my permission for my information showing eligibility

to be sent to OSU-Fire Service Training and COFT.

Daytime phone, with area code

Evening phone, wi th area code

Date

Signature o f Volunteer Firefighte r

If you have finished your 12 hrs of training,

EPARTMENTAL

FFILIATION(S):

RAINING:

then please submit this form NOW!!

CURRENTLY serving as a volunteer firefighter with :

For the tax year 2005, ALL volunteer firefighters who apply must have

completed 12 hours of training, taken during 2005 or in previous years.

Please indicate the type o f department:

Department ID Number

from Sta te Fire Marshal’s Office:

hrs

COURSE TITLE:

Title 11

Title 18

Title 19

GIVEN BY:

Other:

HELD AT:

Sub-state Planning District Number

County

YEAR:

COURSE TITLE:

hrs

Organi zational address

GIVEN BY:

HELD AT:

YEAR:

City, Sta te and Zip

COURSE TITLE:

hrs

GIVEN BY:

eMail address

HELD AT:

YEAR:

COURSE TITLE:

Another volunteer department affiliation?

hrs

Please list the same details on any other(s)

GIVEN BY:

currentl y

previously

on a separate sheet along with your name.

HELD AT:

If another sheet is used, please check here.

YEAR:

COURSE TITLE:

hrs

Are you also associated or have you previously been

GIVEN BY:

associated with a paid department?

HELD AT:

YES, acti ve

YES, re tired

YEAR:

Paid Fire Department

On a separate sheet, list additional courses to make the 12 hrs

and your name. If another sheet is used, please check this box.

State , if not in Oklahoma

hrs = TOTAL =

12 hrs

for Tax Year 2005

Section below is for administrative purposes only. Applicants should not write below this line. Please give this form to your Fire Chief and then mail it.

Section 2. VERIFICATIONS and

ONFIRMATIONS

C. OSU - Fire Service Training verifies that the training shown

above meets the requirements for this tax credit.

A. After completing and signing, please have your Fire Chief sign below.

The volunteer firefighter whose name is shown above is a member

Date

Authori zed Signature for OSU - Fire Servi ce Training

in good standing of our department and has complied with applicable

D. The Council on Firefighter Training [COFT] certifies that

local, state and federal requirements.

this volunteer firefighter is eligible for a tax credit

in the amount of $200.

Date

Signature o f Fire Chief

Date

Authori zed Signature for COFT

Name of the Fire Chief, prin ted

Please enter $200.

on the applicable line

B. Make a copy for your files and department files, then mail original to:

of Form 511CR of your Oklahoma state tax return.

Then, transfer the total of all your credits from 511CR

COFT (Council on Firefighter Training)

to the applicable line labeled for Other Credits in Section 3

PO Box 11507

on your Form 511. Please make a copy of this form (after it was certified)

Oklahoma City, OK 73136

for your records. Enclose the original with your Oklahoma income tax return.

Form 1a - Oklahoma Volunteer Firefighter Tax Credit - 2005

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