Form Dr-116100 - Application For Rescindment Of Tax Credit Allocation For Contributions To Nonprofit Scholarship Funding Organizations (Sfos)


R. 07/11
Application for Rescindment of Tax Credit Allocation for Contributions
Rule 12-29.003
to Nonprofit Scholarship Funding Organizations (SFOs)
Florida Administrative Code
Effective 01/12
(Under sections [ss.] 211.0251, 212.1831, 220.1875, 561.1211, 624.51055,
and 1002.395, Florida Statutes, [F.S.])
Business name ___________________________________________________________________________________________
Federal Employer Identification Number (FEIN)
Mailing address __________________________________________________________________________________________
City ___________________________________________ State _____________ ZIP __________________________________
Contact person ___________________________ Contact’s telephone number ____________________________________
If included in a consolidated Florida corporate income tax return, provide:
Parent Corporation’s FEIN
Original amount of planned contribution $
Confirmation number of original credit allocation application __________________________________________________
Enter the name of the SFO the credit was originally approved for:
Enter the amount you wish to rescind $
Amount to be rescinded by tax (The sum of the amounts by tax cannot exceed the total amount you wish to rescind
above.) (The amount to be rescinded for each tax cannot exceed the amount allocated to that tax on the original
______________ Corporate Income Tax (Chapter 220, F.S.)
______________ Insurance Premium Tax (s. 624.509, F.S.)
______________ Excise Tax on Malt Beverages (s. 563.05, F.S.)
______________ Excise Tax on Wine Beverages (s. 564.06, F.S.)
______________ Excise Tax on Liquor Beverages (s. 565.12, F.S.)
______________ Sales Tax Paid by a Direct Pay Permit Holder (s. 212.183, F.S.)
______________ Tax on Oil Production (s. 211.02, F.S.)
______________ Tax on Gas Production (s. 211.025, F.S.)
Under penalty of perjury, I declare that I have read this application form and that the facts stated in it are true.
Signature of officer, owner, or partner


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