Form 41a720-S86 (2-12) - Notice Of Endow Kentucky Tax Credit And Certification

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Schedule ENDOW
*1200020330*
41A720-S86 (2-12)
NOTICE OF ENDOW KENTUCKY TAX
Commonwealth of Kentucky
CREDIT AND CERTIFICATION
DEPARTMENT OF REVENUE
KRS 141.438
➤ See instructions.
A
B
C
Name of Taxpayer
Federal Identification Number or
Kentucky Corporation/LLET
Social Security Number
Account Number (if applicable)
Street Address or P. O. Box
Telephone
City
State
ZIP Code
Fax Number
D
Type of Entity:
¨ Individual
¨ Estate
¨ Trust
¨ Corporation
¨ Limited Liability Pass-through Entity
¨ General Partnership
¨ Other
E
F
G
Date the Endowment Gift was made to the Approved
Amount of Endowment Gift
Date of the Department’s Pre–
Foundation
liminary Authorization of Credit
/
/
/
/
Mo.
Day
Yr.
Mo.
Day
Yr.
H
I
Name of Qualified Community Foundation
Federal Identification Number
Telephone
or Affiliate Community Foundation
Fax Number
Street Address or P. O. Box
City
State
ZIP Code
J
If applicable, name of Permanent Endowment Fund or County-Specific Component Fund receiving the gift
Under penalties of perjury, I declare that the Foundation is a qualified community foundation as provided by KRS
147A.310(6); that the endowment gift listed above is held in a permanent endowment as provided by KRS 147A.310(4);
and that I have examined this schedule, including all accompanying documents and statements, and to the best of
my knowledge and belief, it is true, correct and complete.
By: _____________________________________________
__________________________________________________
Signature of Foundation Officer (or designee)
Date
Print Name: _____________________________________
Title: ___________________________________________
Department of Revenue Use Only
Endow Kentucky tax credit approved by the Department of Revenue.
Amount
By: ___________________________________________
Date: _____________________
Hand–delivery: Department of Revenue, 1st floor security desk at 501 High Street, Frankfort, Kentucky
Fax: (502) 564-0058
Email: KRC.WEBResponseEconomicDevelopmentCredits@ky.gov

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