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Missouri Department of Revenue
Form
Adoption Tax Credit Claim
MO-ATC
For calendar year 20_____ or other tax year beginning ___________________________ 20_____, ending ___________________ 20______
Adoptive Father’s Name
Social Security Number
Tax Type
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Individual
Corporation
Adoptive Mother’s Name
Social Security Number
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Non-Profit
Other _____________
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Address
City
State
Zip Code
Phone Number
Name of Adopted Child
Social Security Number of Child, If Available
(___ ___ ___)___ ___ ___-___ ___ ___ ___
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Age of Child State or Country of Origin
Birthdate of Child (MM/DD/YYYY)
Date Child Was Placed (MM/DD/YYYY)
Date Adoption Became Final (MM/DD/YYYY)
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1) Was the child a resident of Missouri prior to assignment? ....................................................................................................................................
Yes
No
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2) Did the adoptive parents have legal custody prior to the assignment? .................................................................................................................
Yes
No
___________________________________________
3) Name any other state or federal program utilized for the adoption of a special needs child.
If the “special needs child” was 18 years of age or over on the date the adoption was final, you must attach a statement from the child’s physician indicating that the
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child has a medical condition or handicap that limits the child’s ability to live independently of the adoptive parents.
Check here if you have a statement from the
physician.
Name
Standard Industry Code (SIC)
Phone Number
(___ ___ ___)___ ___ ___-___ ___ ___ ___
Address
Federal Employer Identification Number (FEIN)
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City
State
Zip Code
Missouri Tax Identification Number
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Paid by Adoptive Parent(s)
Paid by Employer
1. Adoption fees ...................................................................................................................................................
1
1
2. Court costs .......................................................................................................................................................
2 +
2 +
3. Attorney fees ....................................................................................................................................................
3 +
3 +
4. Other directly related expenses .......................................................................................................................
4 +
4 +
5. Total nonrecurring expenses
(Employers claiming the credit, enter total on Line 5 and then skip to Line 11.) .............................................
5 =
5 =
6. Amount of nonrecurring expenses paid by Missouri Children’s Division .........................................................
6 +
7. Amount of nonrecurring expenses paid by employer ......................................................................................
7 +
8. Amount of federal adoption tax credit claimed from Federal Form 8839, Line 16 ...........................................
8 +
9. Amount received from other state or local programs .......................................................................................
9
10. Add Lines 6 through 9 and enter on Line 10. ...................................................................................................
10 =
11. Subtract Line 10 from Line 5 and enter the amount on Line 11. (Employer enter amount from Line 5.) ........
11 =
11 =
12. The special needs adoption tax credit is limited to the lesser of the total on Line 11 or $10,000.
Enter the smaller amount on Line 12. ..............................................................................................................
12
12
I hereby certify, to the Department of Revenue, that the adoption expenses itemized in Part C of this schedule have not and will not be reimbursed and paid from funds
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available from the state of Missouri, managed by the Missouri Department of Social Services, Children’s Division
Authorized Signature
Title
Children’s Division County Office
Date (MM/DD/YYYY)
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(To verify that the adopted child has met the necessary criteria and is determined a “special needs child” any other document may be attached to this form if it
reflects the same information as in Part A.) I certify that the adopted child meets the necessary criteria and is determined to be a “special needs child” pursuant to
Section 135.326,
RSMo. (Part E may be shared by: (1) The Missouri Department of Social Services, Children’s Division, or (2) A child placing agency licensed by the
state of Missouri, or (3) A court of competent jurisdiction.)
Authorized Signature
Office of
Date (MM/DD/YYYY)
___ ___ / ___ ___ / ___ ___ ___ ___
Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.
Adoptive Father’s Signature
Date (MM/DD/YYYY)
Adoptive Mother’s Signature
Date (MM/DD/YYYY)
___ ___ / ___ ___ / ___ ___ ___ ___
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Phone Number
Name of Agent or Contact
Address, City, State, Zip Code
(___ ___ ___)___ ___ ___-___ ___ ___ ___
Form MO-ATC (Revised 12-2013)
Mail to:
Phone: (573) 526-8733
Taxation Division
Visit
Fax: (573) 751-7744
P.O. Box 27
for additional information.
Jefferson City, MO 65105-0027
TDD: 1-800-735-2966
E-mail:
income@dor.mo.gov