Form Rev-1123 Ct - Educational Improvement/opportunity Scholarship Tax Credit Election Form

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REV-1123 CT (02-13)
EDUCATIONAL IMPROVEMENT/
OPPORTUNITY SCHOLARSHIP
TAX CREDIT ELECTION FORM
BUREAU OF CORPORATION TAXES
PO BOX 280701
See Page 3 for instructions.
HARRISBURG PA 17128-0701
GO TO INSTRUCTION PAGE
Irrevocable election to pass Educational Improvement Tax Credit (EITC)/Opportunity Scholarship Tax Credit (OSTC)
through to shareholders, members or partners. A separate election must be submitted for each year an EITC/OSTC is awarded and
not used in whole or in part by the contributing entity. DO NOT INCLUDE THIS ELECTION WITH YOUR TAX REPORT.
SECTION I
Pass-Through Entity Name:
Date Received: Department Use Only
START
MMDDYYYY
Address:
Telephone Number:
Fax Number:
Email Address:
Identification Number (Revenue ID, FEIN, SSN):
(1) Total EITC/OSTC awarded in tax year __________ available for pass through:
Contribution Date:
Amount:
YYYY
$
$
$
$
$
MMDDYYYY
TOTAL
$
(2) Amount of EITC/OSTC to be applied to the entity’s liability.
$
(3) Amount of EITC/OSTC to be passed through to shareholders, members or partners.
$
NOTE: Please answer “yes” to only one of the following questions, as an EITC/OSTC may be passed through for use by owners in one
tax year only.
o
o
(A) Will the remaining EITC/OSTC be passed through for use by the owner(s) in the year of contribution?
yes
no
(B) Will the remaining EITC/OSTC be passed through for use by the owner(s) in the year immediately
o
o
following the year of contribution?
yes
no
Please complete and attach Section II.
I, the undersigned, declare and certify I am a corporate officer, general partner or limited liability company member of the above-
named entity, and I have authority to bind the above-named entity to the terms and conditions of this election.
Signature of Company Official:
Date:
Please remember to sign your form after printing.
MMDDYYYY
Printed Name:
Printed Title or Affiliation to the Entity:
Telephone Number:
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