Credit for Contributions to Charities
ARIZONA FORM
2004
That Provide Assistance to the Working Poor
321
For the calendar year 2004, or
M M D D
2 0 0 4
M M D D
2 0 0 5
fi scal year beginning
and ending
.
Attach to your return
NAME(S) AS SHOWN ON FORM 140, 140NR, 140PY OR 140X
YOUR SOCIAL SECURITY NO.
SPOUSE’S SOCIAL SECURITY NO.
Part I
Current Year’s Credit
1a Name of qualifying charity to which you made contributions:
00
Amount contributed to organization named on line 1a ..................................
1a
1b Name of qualifying charity to which you made contributions:
00
Amount contributed to organization named on line 1b ..................................
1b
NOTE: If you made contributions to more than two qualifying charities, attach a separate schedule.
00
1c Total: Add lines 1a and 1b. Also, add any amount included on a separate schedule....................
1c
00
2 Potential credit: enter the lesser of line 1c or $200 ........................................................................
2
00
3 Total contributions allowable as an itemized deduction for 2004...................
3
4 Baseline year: ___________
5 Total contributions deducted as an itemized deduction on your Arizona
00
return for the baseline year listed on line 4 ...................................................
5
00
6 Subtract line 5 from line 3. If line 5 is greater than line 3, no credit is available. ............................
6
00
7 Current year’s credit: Enter the lesser of line 2 or line 6 ................................................................
7
Part II Available Credit Carryover
(a)
(b)
(c)
(d)
Taxable Year
from which you are
Available Carryover:
carrying the credit
Original Credit Amount
Amount Previously Used
Subtract column (c) from column (b).
$
$
$
8
1999
$
$
$
9
2000
$
$
$
10
2001
$
$
$
11
2002
$
$
$
12
2003
$
13
TOTAL AVAILABLE CARRYOVER
Part III Total Available Credit
00
14 Current year’s credit: Enter the amount from Part I, line 7 .............................................................
14
00
15 Enter the amount of available carryover from Part II, line 13, column (d) .......................................
15
16 Total Available Credit: Add line 14 and line 15, and enter the total here. See page 2 of
00
the instructions. ...............................................................................................................................
16
ADOR 91-5457f (04)
Previous 91-0011