Form Rev-984 - Pennsylvania Organ & Bone Marrow Donor Tax Credit
ADVERTISEMENT
1REV-984 (06-08) PC
PENNSYLVANIA
ORGAN & BONE MARROW DONOR
BUREAU OF CORPORATION TAXES
CD&S DIVISION – OBMD UNIT
TAX CREDIT
PO BOX 280700
HARRISBURG PA 17128-0700
Account ID (Box Number/SSN)
Entity ID (EIN)
BUSINESS FIRM INFORMATION – (PLEASE PRINT OR TYPE)
Entity Type
Entity Name
Sole Proprietorship
Bank or Trust Company
Partnership
Title Insurance Company
Estate/Trust
Insurance Company
Street Address
Mutual Thrift
PA S Corporation
Corporation
City or Town, State and ZIP Code
Limited Liability Company
COMPUTATION OF CREDIT
1. Tax Period Beginning Date ____________________ Tax Period Ending Date _____________________________
2. Number of employees donating an organ or bone marrow during tax year 2007 _____________________________.
3. Use the table below to itemize each employee’s compensation paid during an absence to donate an organ or bone marrow.
If more than three employees donated organs or bone marrow, please include a separate sheet detailing the information
shown below for additional employees.
Beginning Date of
Ending Date of
Employee
SSN
Absence
Absence
Employee Compensation
Last Name, First Name
a.
$
b.
$
c.
$
4. TOTAL
$
5. Use the table below to itemize cost of temporary replacement help. If more than three replacements were temporarily
employed, please include a separate sheet detailing the information shown below for additional occurrences.
Table 3
Beginning Date
Ending Date of
Cost of Temporary
Temporary Help
EIN/SSN
Reference #
of Service
Service
Help Paid
a.
$
b.
$
c.
$
6. TOTAL
$
7. Total Organ & Bone Marrow Donor Tax Credit requested (Line 4 + Line 6)
$_________________________
8. Apportionment Factor – Total Compensation paid in the Commonwealth divided by
___. ___ ___ ___ ___ ___ ___
Total Compensation paid Everywhere
9. Pennsylvania Organ & Bone Marrow Donor Tax Credit (Line 7 X Line 8)
$________________________
SIGNATURE AND VERIFICATION
Under penalties of perjury, I declare I have examined this return, including accompanying schedules and statements, and to the best of
my knowledge and belief it is true, correct and complete. THIS FORM MUST BE SIGNED BY A CORPORATE OFFICER.
SIGNATURE OF OFFICER OF COMPANY
TITLE
DATE
PRINT OFFICER’S NAME
TELEPHONE NUMBER
E-MAIL ADDRESS
(
)
NAME OF PREPARER
PREPARER’S ADDRESS
TELEPHONE NUMBER
PREPARER’S EIN OR SSN
DATE
CITY
STATE
ZIP CODE
(
)
Department Use Only
POSTMARK DATE:
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial