State Form 21926 - Schedule Lic - Enterprise Zone Loan Interest Tax Credit
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4Indiana Department of Revenue
SCHEDULE LIC
814
Enterprise Zone
State Form 21926
(R9 / 8-12)
Loan Interest Tax Credit
For Tax Year Ending:
(Enclose completed schedule with annual state tax liability return.)
Enclosure Sequence No. 28
Month_________ Year _______
Section A - Taxpayer Information
Name of Taxpayer (lender)
Social Security or Federal Identification Number
Street Address
County
City or Town, State, and ZIP Code
Taxpayer's Telephone Number
(
)
Section B - Qualified Loan Information (attach list of all borrowers) Section B continued on reverse side.
Name of Borrower (A)
Borrower's Social Security or Federal Identification Number
Street Address
Borrower's Telephone Number
City or Town, State, and ZIP Code
Use of Loan (check one):
Date of Loan Origination:
Location Name of Borrower's Enterprise Zone
Business
Personal
Section C - Report of Qualified Loans to Businesses by Enterprise Zone Locations
Summarize the number of qualified loans to businesses in each enterprise zone and the amount of interest received during the taxable year.
Number
Interest
Number
Interest
(d)
(a)
(b)
(c)
Enterprise Zone
of Loans
Income
Enterprise Zone
of Loans
Income
Bedford
$
Jeffersonville
$
00
00
Bloomington
$
00
Kokomo
$
00
00
00
Connersville
$
Lafayette
$
00
00
East Chicago
$
La Porte
$
Elkhart
$
Marion
$
00
00
00
00
Evansville
$
Michigan City
$
00
00
Ft. Harrison
$
Mitchell
$
00
00
Ft. Wayne
$
New Albany
$
Frankfort
$
00
Portage
$
00
Gary
$
Richmond
$
00
00
Grissom Aeroplex
$
Salem
$
00
00
00
00
Hammond
$
South Bend
$
00
00
Indiana Army Ammunition Plant
$
Terre Haute
$
00
00
Indianapolis
$
Vincennes
$
00
00
Subtotal
$
Subtotal
$
Section D - Credit for Qualified Loans for the Taxable Year
00
1. Grand total of all qualified loans to businesses listed in Section C, columns (a) and (c) ............................ 1 $
2 Total amount of loan interest income received from qualified loans in Section C, columns (b) and (d) ........... 2 $
00
3. Amount of loan interest income received from other qualified nonbusiness loans made for home
00
improvements within all enterprise zones ................................................................................................... 3 $
4. Total Loan Interest Credit - add amounts on lines 2 and 3; multiply result by 5 percent (.05) .................... 4 $
00
5. Indicate for which tax type you are applying this credit. Enter net amount of tax you are offsetting:
00
a
Adjusted Gross Income Tax
b
Insurance Premium Tax
c
Financial Institutions Tax ....... 5 $
The tax offset may not exceed the amount of available credit from line 4. Carry amount on line 5 to other credit line of your return.
00
6. Unused amount of credit available for carryover - subtract line 5 from line 4 and complete Section E ...... 6 $
*24100000000*
24100000000
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