Schedule Cg-Dist - Form 48681 - Charitable Contribution Distribution Listing (Page 2 of 2) in pdf

Schedule Cg-Dist - Form 48681 - Charitable Contribution Distribution Listing Page 2

Recipient's Federal I.D. Number,

Check If This is

Distribution

Name of Recipient to Whom

Amount Contributed

a Qualified

Indiana TID Number or

Date

to Recipient

Contribution Was Made

Social Security Number

Recipient

Total amount distributed for charitable purposes.

Add lines 1 through 33 ............................................... TOTAL

A qualified recipient is: 1) a bona fide religious, educational, senior citizens, veterans, or civic organization operating in Indiana that is

exempt from taxation under Section 501 of the Internal Revenue Code, and which must have been continuously in existence for at least five

years or be affiliated with a parent organization that has been in existence for at least five years; 2) a bona fide political organization

operating in Indiana that produces exempt function income; 3) a hospital or medical center operated by the federal government; 4) a

hospital licensed under IC 16-21; 5) a hospital subject to IC 16-22 or IC 16-23; 6) a health facility or psychiatric facility licensed under IC 16-

28 and IC 12-25, respectively; 7) an activity or program of a local law enforcement agency intended to reduce substance abuse; 8) a

charitable activity of a local law enforcement agency; or 9) a veterans' home, which is the Indiana Veterans' Home, the VFW National Home

for Children, and/or the Indiana Soldiers' and Sailors' Childrens Home. (Note: For the purpose of being a qualified recipient, a veterans'

home is not considered to be an affiliate, a parent, or a subsidiary organization of a qualified organization that is a bona fide veterans'

organization.)

Under penalty of perjury, I have examined this schedule and, to the best of my knowledge and belief, it is true, complete and correct.

(

)

Signature of Schedule Preparer

Date

Daytime Telephone Number

Attach additional sheets if necessary.

Schedule Cg-Dist - Form 48681 - Charitable Contribution Distribution Listing Page 2