Form F-1159 - Application For Child Care Tax Credits
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1Florida Department of Revenue
F-1159
N. 12/98
Application for Child Care Tax Credits
(Under Sections 220.19 or 624.5107, Florida Statutes)
For Taxable Year Beginning ___________________,________, and Ending___________________,________
Joint Application
Business Information
Facility Information
Business FEIN: _______________________________________
Facility FEIN: ________________________________________
Business Name: ______________________________________
Facility Name: _______________________________________
Mailing Address: _____________________________________
Mailing Address: _____________________________________
City: _______________________________________________
City: _______________________________________________
State: _____________________ Zip: _____________________
State: _____________________ Zip: _____________________
Street Address (if different): _____________________________
Street Address (if different): _____________________________
City: _______________________________________________
City: _______________________________________________
State: _____________________ Zip: _____________________
State: _____________________ Zip: _____________________
E-Mail Address: ______________________________________
E-Mail Address: ______________________________________
Phone: ____________________ Fax No: __________________
Phone: ____________________ Fax No: __________________
Child Care Facility License Number: ______________________
(Indicate N/A where the facility is providing daily care to mildly ill
children and not required to be licensed. Written verification by the
Department of Children and Families or a local licensing agency
must be provided in all cases before approval can be granted to take
the credit. Please refer to the instructions.)
:
Basis of Credit
(check those that apply)
1) Establishment of a facility (start-up costs).
$__________________ Start-up costs (attach detailed list).
2) Operation of a facility ($50 per month for each child enrolled).
Jan.
Feb.
March
April
May
June
July
Aug.
Sept.
Oct.
Nov.
Dec.
Total
No. of
Children
3) Payments made directly to facilities (50% of the amount of such payments that are not higher than the
amounts charged by the facility to other children of like age and abilities of persons not employed by the
corporation).
Jan.
Feb.
March
April
May
June
July
Aug.
Sept.
Oct.
Nov.
Dec.
Total
No. of
Children
Monthly
Payment
I hereby certify that this application form has been examined by me and the information contained herein
is, to the best of my knowledge and belief, true, correct, and complete.
Send completed form to:
Florida Department of Revenue
Building F-3
____________________________________________________
______________________
5050 W. Tennessee St.
Signature of Officer, Owner or Partner
Date
Tallahassee, FL 32399-0100
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