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Form 41a720-S85 - Application For Preliminary Authorization Of The Endow Kentucky Tax Credit

APPLICATION FOR PRELIMINARY AUTHORIZATION

41A720-S85 (2-13)

OF THE ENDOW KENTUCKY TAX CREDIT

Commonwealth of Kentucky

DEPARTMENT OF REVENUE

KRS 141.438

➤ See instructions.

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

Type of Entity:

¨ Individual

¨ Estate

¨ Trust

¨ Corporation

¨ Limited Liability Pass-through Entity

¨ General Partnership

¨ Other

Submission Date of Application

Amount of Endowment Gift

Amount of Tax Credit

Mo.

Day

Yr.

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

If applicable, name of Permanent Endowment Fund or County-Specific Component Fund receiving the gift

Under penalties of perjury, I declare that I have examined the application, including all accompanying documents

and statements, and to the best of my knowledge and belief, it is true, correct and complete.

By: _____________________________________________

__________________________________________________

Signature of Taxpayer or Authorized Representative

Date

Print Name: _____________________________________

Title: ___________________________________________

Department of Revenue Use Only

Preliminary authorization of Endow Kentucky tax credit.

Amount

By: ___________________________________________

Date: _____________________

Hand–delivery: Department of Revenue, 1st floor security desk at 501 High Street, Frankfort, Kentucky

Fax: (502) 564-0058

E-mail: KRC.WEBResponseEconomicDevelopmentCredits@ky.gov

Form 41a720-S85 - Application For Preliminary Authorization Of The Endow Kentucky Tax Credit

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