Form Rev-984 - Pennsylvania Organ & Bone Marrow Donor Tax Credit
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2FILL IN FORM USING ALL CAPS. DO NOT USE DASHES (-) OR SLASHES (/) IN ANY FIELD. ENTER DATES AS MMDDYYYY. USE WHOLE DOLLARS ONLY.
REV-984 (05-14)
DEPARTMENT USE ONLY
PENNSYLVANIA ORGAN &
POSTMARK DATE:
BONE MARROW DONOR
BUREAU OF CORPORATION TAXES
TAX CREDIT
CD&S DIVISION – OBMD UNIT
PO BOX 280700
START
HARRISBURG PA 17128-0700
BUSINESS FIRM INFORMATION – (PLEASE PRINT OR TYPE)
Revenue ID/SSN
Federal Employer Identification
Number (FEIN)
Entity Name
Entity Type
Sole Proprietorship
Bank or Trust Company
Street Address
Partnership
Title Insurance Company
Estate/Trust
Insurance Company
Mutual Thrift
City or Town, State and Zip
PA S Corporation
Corporation
Limited Liability Company
CALCULATION OF CREDIT
MMDDYYYY
MMDDYYYY
1. Tax period beginning date
Tax period ending date
2. Number of employees donating an organ or bone marrow during the current tax year.
3. Use the table below to itemize each employee’s compensation paid during an absence to donate an organ or bone marrow. If more
than three employees donated an organ or bone marrow, please include a separate schedule detailing the information shown
below for additional employees.
MMDDYYYY
MMDDYYYY
Employee
Beginning Date
Ending Date
SSN
Employee Compensation
Last Name, First Name
of Absence
of Absence
a.
$
b.
$
c.
$
4. TOTAL
$
5. Use the table below to itemize cost of temporary replacement help. If more than three replacements were temporarily employed,
please include a separate schedule detailing the information shown below for additional occurrences.
MMDDYYYY
MMDDYYYY
Table 3
Beginning Date
Ending Date
Cost of Temporary
Temporary Help
FEIN/SSN
Reference #
of Service
of Service
Help Paid
a.
$
b.
$
c.
$
6. TOTAL
$
7. Total Organ & Bone Marrow Donor Tax Credit requested (Line 4 plus Line 6)
$
Total compensation paid in the commonwealth
8. Apportionment factor –
divided by
.
Total compensation paid everywhere
9. Pennsylvania Organ & Bone Marrow Donor Tax Credit (Line 7 times Line 8)
$
SIGNATURE AND VERIFICATION
Under penalties of perjury, I declare that I have examined this return, including any accompanying schedules and statements, and to
the best of my knowledge and belief it is true, correct, and complete. THIS FORM MUST BE SIGNED BY A CORPORATE OFFICER.
MMDDYYYY
SIGNATURE OF OFFICER
TITLE
DATE
PLEASE SIGN AFTER PRINTING
PRINT OFFICER’S NAME
TELEPHONE NUMBER
EMAIL ADDRESS
NAME OF PREPARER
PREPARER’S ADDRESS
MMDDYYYY
TELEPHONE NUMBER
PREPARER’S FEIN OR SSN
DATE
CITY
STATE
ZIP
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