Form Rv-F1319401 - Tennessee Rural Opportunity Fund Tax Credit Certificate Of Contribution For Tax Credit
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1Tennessee Department of Revenue
Tennessee Rural Opportunity Fund Tax Credit
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
Type of Contribution (Check All That Apply):
Qualified Contribution
$ ____________ Date Approved ______________
Qualified loan
$ ____________ Date Approved ______________
Submitted by:
Name of Financial Institution
By:
Signature
Date
Print Name and Title
PART 2 - DEPARTMENT OF REVENUE CERTIFICATION (Completed by Revenue)
Amount of Tax Credit:
Approved by:
Signature
Print Name and Title
Date
RV-F1319401
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