Fillable Form Mo-Atc - Adoption Tax Credit Claim printable pdf download

Missouri Department of Revenue

Form

Adoption Tax Credit Claim

MO-ATC

For calendar year 20_____ or other tax year beginning ___________________________ 20_____, ending ___________________ 20______

Adoptive Father’s Name

Social Security Number

Tax Type

Individual

Corporation

Adoptive Mother’s Name

Social Security Number

Non-Profit

Other _____________

Address

City

State

Zip Code

Phone Number

Name of Adopted Child

Social Security Number of Child, If Available

(___ ___ ___)___ ___ ___-___ ___ ___ ___

Birthdate of Child (MM/DD/YYYY)

Date Child Was Placed (MM/DD/YYYY)

Date Adoption Became Final (MM/DD/YYYY)

Age of Child State or Country of Origin

___ ___ / ___ ___ / ___ ___ ___ ___

1) Was the child a resident of Missouri prior to assignment? ....................................................................................................................................

Yes

2) Did the adoptive parents have legal custody prior to the assignment? .................................................................................................................

Yes

___________________________________________

3) Name any other state or federal program utilized for the adoption of a special needs child.

If the “special needs child” was 18 years of age or over on the date the adoption was final, you must attach a statement from the child’s physician indicating that the

child has a medical condition or handicap that limits the child’s ability to live independently of the adoptive parents.

Check here if you have a statement from the

physician.

Name

Standard Industry Code (SIC)

Phone Number

(___ ___ ___)___ ___ ___-___ ___ ___ ___

Address

Federal Employer Identification Number (FEIN)

City

State

Zip Code

Missouri Tax Identification Number

Paid by Adoptive Parent(s)

Paid by Employer

1. Adoption fees ...................................................................................................................................................

2. Court costs .......................................................................................................................................................

2 +

3. Attorney fees ....................................................................................................................................................

3 +

4. Other directly related expenses .......................................................................................................................

4 +

5. Total nonrecurring expenses

(Employers claiming the credit, enter total on Line 5 and then skip to Line 11.) .............................................

5 =

6. Amount of nonrecurring expenses paid by Missouri Children’s Division .........................................................

6 +

7. Amount of nonrecurring expenses paid by employer ......................................................................................

7 +

8. Amount of federal adoption tax credit claimed from Federal Form 8839, Line 16 ...........................................

8 +

9. Amount received from other state or local programs .......................................................................................

10. Add Lines 6 through 9 and enter on Line 10. ...................................................................................................

10 =

11. Subtract Line 10 from Line 5 and enter the amount on Line 11. (Employer enter amount from Line 5.) ........

11 =

12. The special needs adoption tax credit is limited to the lesser of the total on Line 11 or $10,000.

Enter the smaller amount on Line 12. ..............................................................................................................

I hereby certify, to the Department of Revenue, that the adoption expenses itemized in Part C of this schedule have not and will not be reimbursed and paid from funds

available from the state of Missouri, managed by the Missouri Department of Social Services, Children’s Division

Date (MM/DD/YYYY)

Authorized Signature

Title

Children’s Division County Office

___ ___ / ___ ___ / ___ ___ ___ ___

(To verify that the adopted child has met the necessary criteria and is determined a “special needs child” any other document may be attached to this form if it

reflects the same information as in Part A.) I certify that the adopted child meets the necessary criteria and is determined to be a “special needs child” pursuant to

Section 135.326,

RSMo. (Part E may be shared by: (1) The Missouri Department of Social Services, Children’s Division, or (2) A child placing agency licensed by the

state of Missouri, or (3) A court of competent jurisdiction.)

Authorized Signature

Office of

Date (MM/DD/YYYY)

___ ___ / ___ ___ / ___ ___ ___ ___

Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.

Adoptive Father’s Signature

Adoptive Mother’s Signature

Date (MM/DD/YYYY)

___ ___ / ___ ___ / ___ ___ ___ ___