Form Rev-774 Ct - Assignment Of Tax Credit

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REV-774 CT (05-12)
ASSIGNMENT
OF
TAX CREDIT
ACCOUNTING DIVISION
PO BOX 280701
HARRISBURG PA 17128-0701
Please Type or Print
This notice is to authorize the assignment of tax credit(s)
PLEASE SUBMIT IN DUPLICATE
From:
Assignor (holder of the credit)
START
Name of Owner (Individual, Partnership, Corporation, etc.)
Federal Employer Identification Number
Trade Name (If other than preceding line)
Type of Tax (Sales, Corporation, etc.)
Street Address
City
State
ZIP
Revenue ID Number
TYPE OF TAX AND IDENTIFICATION NUMBER
MONTH/YEAR OR TAX NOTICE NUMBER
CREDIT AMOUNT
To:
Assignee (receiver of credit)
Name of Owner (Individual, Partnership, Corporation, etc.)
Federal Employer Identification Number
Trade Name (If other than preceding line)
Type of Tax (Sales, Corporation, etc.)
Street Address
City
State
ZIP
Revenue ID Number
TYPE OF TAX AND IDENTlFlCATION NUMBER
MONTH/YEAR OR TAX NOTICE NUMBER
AMOUNT TO BE CREDITED
For value received, the above-named assignor sells, transfers and assigns to the assignee, the credit(s) listed above
MONTH/YYYY
DAY
Signed this
day of
If Proprietorship or Partnership:
If Corporation:
Please Sign after printing.
Signature
Signature of Corporate Officer
Please Sign after printing.
Signature
Officer Title
Telephone Number
-
-
Reset Entire Form
PRINT FORM
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