Form R-6111 - Agreement To Transfer Tax Credits - 2016
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12016
R-6111 (2/17)
Agreement to Transfer Tax
Credits
This form evidences a binding agreement to transfer Tax Credits. Use this form to transfer credits that are to be claimed for calendar tax
year 2016 or fiscal tax years ending in 2017.
PLEASE PRINT OR TYPE
Taxpayer Information
Name
LA Revenue Account Number or Social Security Number
Address
Spouse’s Social Security Number if Joint Filer
City
State
ZIP
Telephone Number
Transferor Information
Name
Telephone Number
Address
Fax
City
State
ZIP
Email
Agreement by Taxpayer – Notarized Signature Required
Taxpayer hereby agrees to acquire Tax Credits from the Transferor. Taxpayer hereby acknowledges that failure to execute this form prior to the due date
of the return, without regard to the granting of any extension, will prevent any credits purchased pursuant to this binding agreement from being claimed
on any return subsequently filed by the transferee. Further, taxpayer hereby acknowledges that execution of this form will in no way alter or change the
tax period against which the purchased credits may be applied. Finally, taxpayer hereby acknowledges that failure to purchase credits from the transferor
named herein in accordance with the terms of this binding agreement will result in the imposition of all applicable penalties and interest from the due date
of the return, without regard to the granting of any extension.
Signature of Taxpayer or Taxpayer’s Authorized Representative
Print Name
Title
Date
(mm/dd/yyyy)
Sworn to and subscribed by Taxpayer before me this
day of
,
.
____________
_______________________________________
_________________
Signature of Notary Public
____________________________________________________________________________________________________________________________________
Printed Name of Notary Public
________________________________________________________________________________________________________________________________
Agreement by Transferor – Notarized Signature Required
Transferor hereby agrees to transfer Tax Credits to the Taxpayer.
Print Name
Signature of Transferor or Transferor’s Authorized Representative
Title
Date
(mm/dd/yyyy)
Sworn to and subscribed by Taxpayer before me this
day of
,
.
____________
_______________________________________
_________________
Signature of Notary Public
____________________________________________________________________________________________________________________________________
Printed Name of Notary Public
________________________________________________________________________________________________________________________________
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