DLN
FORM
MISSOURI DEPARTMENT OF REVENUE
MO-ATC
ADOPTION TAX CREDIT CLAIM
(REV. 09-2011)
FOR CALENDAR YEAR 20
OR OTHER TAX YEAR BEGINNING
20
, ENDING
20
PART A — ADOPTED SPECIAL NEEDS CHILD INFORMATION
ADOPTIVE FATHER’S NAME
SOCIAL SECURITY NUMBER
TAX TYPE
__ __ __ - __ __ - __ __ __ __
Individual
Corporation
ADOPTIVE MOTHER’S NAME
SOCIAL SECURITY NUMBER
Non-Profit
Other ______________
__ __ __ - __ __ - __ __ __ __
ADDRESS
CITY, STATE, AND ZIP CODE
TELEPHONE NUMBER
(__ __ __ ) __ __ __ - __ __ __ __
NAME OF ADOPTED CHILD
STATE OR COUNTRY OF ORIGIN
SOCIAL SECURITY NUMBER OF CHILD, IF AVAILABLE
AGE OF CHILD
BIRTHDATE OF CHILD
DATE CHILD WAS PLACED
DATE ADOPTION BECAME FINAL
__ __ / __ __ / __ __ __ __ __ __ / __ __ / __ __ __ __
1) Was the child a resident of Missouri prior to assignment?
YES
NO
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 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.
PART B — EMPLOYER INFORMATION (IF CLAIMING CREDIT)
NAME OF EMPLOYER
STANDARD INDUSTRY CODE (SIC)
PHONE NUMBER
(__ __ __ ) __ __ __ - __ __ __ __
ADDRESS
CITY, STATE, AND ZIP CODE
FEDERAL I.D. NUMBER
MO TAX I.D. NUMBER
__ __ __ __ __ __ __ __ __
__ __ __ __ __ __ __ __
PART C — NONRECURRING ADOPTION EXPENSES (see back of form for instructions)
Paid by Adoptive
Paid by Employer
Parent(s)
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 ADOPTION 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 .............................................................................................................................
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 credit is limited to the lesser of the total on Line 11 or $10,000. ..................................................... 12
12
PART D — VERIFICATION THAT NONRECURRING EXPENSES WILL NOT BE REIMBURSED
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
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
_ _ / _ _ / _ _ _ _
PART E — VERIFICATION OF “SPECIAL NEEDS CHILD”
(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
DATE OF CERTIFICATION
OFFICE OF
__ __ / __ __ / __ __ __ __
Under penalties of perjury, I declare that I have examined the above information, including accompanying schedules and statements, and to the best of my knowledge and belief it is true, correct, and complete. I also declare under penalties of perjury that I employ no
illegal or unauthorized aliens as defined under federal law and that I am not eligible for any tax exemption, credit or abatement if I employ such aliens. I also declare that if I am a business entity, I participate in a federal work authorization program with respect to the
employees working in connection with any contracted services and I do not knowingly employ any person who is an unauthorized alien in connection with any contracted services.
ADOPTIVE FATHER’S SIGNATURE
DATE
ADOPTIVE MOTHER’S SIGNATURE
DATE
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
NAME OF AGENT OR CONTACT
ADDRESS
CITY, STATE, AND ZIP CODE
PHONE NUMBER
(__ __ __ ) __ __ __ - __ __ __ __
MO-ATC (09-2011)