Shedule Lic Form - Enterprise Zone Loan Interest Tax Credit - 2003

Indiana Department of Revenue

Enterprise Zone

SCHEDULE

For Tax Year Ending:

Loan Interest Tax Credit

LIC

Month_________ Year _______

State Form 21926

(Attach completed form to annual income tax return)

(9-03)

Name of taxpayer (lender)

Social security or federal identification number

Street address

Taxpayer's calendar or fiscal year

City or town, state and zip code

County

Taxpayer's telephone number

(

)

Loan Information

PART I

Name of borrower

Location name of Enterprise Zone

Street address

City or town, state and zip code

County

Borrower's telephone number

Purpose of loan

Borrower's social security or federal identification number

Credit Calculation

PART II

1.

$

1. Qualified interest income received from loan described in PART I ...........................................................................................................

2. Loan Interest Credit - multiply the amount on line 1 by 5% (.05) .............................................................................................................. 2.

$

PART III

Enterprise Zone Interest Credit Carryover

Enter below the tax period during which the Enterprise Zone Loan Interest Credit originated. Also enter the amount of the credit as it appeared on

the original return. DO NOT enter the sum of this year's credit plus any available credit carryover; rather, complete separate schedules for each year

a credit is available.

Enterprise Zone Loan Interest

Tax Year Ending

Credit Available For

Carryforward

(1)

(2)

(3)

(4)

(5)

Total

Type of Tax

Credit Carryforward

Amount of Tax

Liability Reduced

Amount Applied

Unused Credit

1st Following Tax Year

2nd Following Tax Year

3rd Following Tax Year

4th Following Tax Year

5th Following Tax Year

6th Following Tax Year

7th Following Tax Year

8th Following Tax Year

9th Following Tax Year

10th Following Tax Year

I certify, I have examined this schedule, and to the best of my knowledge and belief, the information contained in this schedule is true, correct and complete.

Signature of taxpayer:

Title:

Date signed

: