State Form 21926 - Schedule Lic - Enterprise Zone Loan Interest Tax Credit Page 2
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Schedule LIC
Section B - Qualified Loan Information Continued (Attach additional sheets if necessary.)
Name of Borrower (B)
Borrower's Social Security or Federal Identification Number
Street Address
Borrower's Telephone Number
City or Town, State, and ZIP Code
Use of Loan (Business or Personal):
Date of Loan Origination:
Location Name of Borrower's Enterprise Zone
Name of Borrower (C)
Borrower's Social Security or Federal Identification Number
Street Address
Borrower's Telephone Number
City or Town, State, and ZIP Code
Use of Loan (Business or Personal):
Date of Loan Origination: Location Name of Borrower's Enterprise Zone
Name of Borrower (D)
Borrower's Social Security or Federal Identification Number
Street Address
Borrower's Telephone Number
City or Town, State, and ZIP Code
Use of Loan (Business or Personal):
Date of Loan Origination: Location Name of Borrower's Enterprise Zone
Section E - Enterprise Zone Interest Credit Carryover (814)
Enter the initial tax period in which the Enterprise Zone Loan Interest Credit was claimed. Enter the remaining unused amount of credit
from Section D, line 6.
Enterprise Zone Loan Interest Credit Available
Initial Tax Year Ending:
for Carryforward from Section D, Line 6: $_______________________________
Month ________________ Year_________
Show how the unused credit is applied during the carryover period. Unused Credit (column 5) is to be placed on your return for the next tax year.
(1)
(2)
(3)
(4)
(5)
Total
Type of Tax
Credit Carryforward
Amount of Tax
Liability Reduced
Amount Applied
Unused Credit
1st Following Tax Year
2nd Following Tax Year
3rd Following Tax Year
4th Following Tax Year
5th Following Tax Year
6th Following Tax Year
7th Following Tax Year
8th Following Tax Year
9th Following Tax Year
10th Following Tax Year
Section F - Signature
I certify I have examined this schedule and, to the best of my knowledge and belief, the information contained in this schedule is true,
correct, and complete.
Signature of Taxpayer:
Title:
Date Signed:
*24100000000*
24100000000
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