Schedule Fd (Form 41a720fd) - Food Donation Tax Credit printable pdf download

SCHEDULE FD

Taxable Year Ending

*1300010340*

__ __ / __ __

41A720FD (06-13)

Mo.

Yr.

Commonwealth of Kentucky

DEPARTMENT OF REVENUE

OOD

ONATION

REDIT

KRS 141.392

➤ Attach to Form 720, 720S, 725, 740, 740-NP, 741, 765 or 765-GP.

Name of Entity (Donor)

Identification Number (SSN or FEIN)

Kentucky Corporation/LLET Account Number

(if applicable)

__ __ __ __ __ __

__ __ __ __ __ __ __ __ __

Address (Number, Street, and Room or Suite No.)

City, State and Zip Code

Part I - Information on Donated Food - To be completed by taxpayer making the donation and/or donee

 Fruits

 Vegetables

 Beef

 Poultry

 Pork

 Fish

 Other edible product __________________________________

Description of

Date

Quantity of

Fair Market Price

Fair Market Value

Donated Food

Donated

Donation

Per Unit of Measure

(multiply Column C by Column D)

7. Total fair market value of donation (add Column E, lines 1 through 6) .............................

8. Credit percentage

10%

9. Credit amount. Multiply line 7 by line 8. Enter result here and on applicable form

or schedule ..............................................................................................................................

Part II - Taxpayer (Donor) Statement

I, the undersigned, declare under the penalties of perjury, that to the best of my knowledge and belief, the information

and fair market values included in Part I are true, correct and complete.

Signature of Taxpayer (Donor) ________________________________________________________

Date __________________________________

_____________________________________________________________________________________

Type Name and Title of Person Signing This Document

Part III - Donee Acknowledgement - To be completed by the charitable organization

I, the undersigned, declare under the penalties of perjury, that this charitable organization is exempt from federal

income tax under Section 501(c)(3) of the Internal Revenue Code, that it operates a surplus food collection and

distribution program as defined in KRS 141.392(1)(c), and that I have examined this schedule, and to the best of my

knowledge and belief, it is true, correct and complete.

Name of Charitable Organization (Donee)

Employer Identification Number

Address (Number, Street, and Room or Suite No.)

City, State and Zip Code

Authorized Signature

Title

Date

Schedule Fd (Form 41a720fd) - Food Donation Tax Credit

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