Form Rev-1123 Ct - Educational Improvement Tax Credit Election Form
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3REV-1123 CT (05-12)
EDUCATIONAL IMPROVEMENT
TAX CREDIT ELECTION FORM
BUREAU OF CORPORATION TAXES
GO TO INSTRUCTION PAGE
PO BOX 280701
See Page 3 for instructions.
HARRISBURG PA 17128-0701
Irrevocable election to pass Educational Improvement Tax Credit (EITC) through to shareholders, members
or partners. A separate election must be submitted for each year an EITC is awarded and not used in whole or in part
by the contributing entity. DO NOT INCLUDE THIS ELECTION WITH YOUR TAX REPORT.
SECTION I
Pass-Through Entity Name:
Date Received: Department Use Only
START
MMDDYYYY
Address:
Phone Number:
Fax Number:
Email Address:
Identification Number (Revenue ID, FEIN, SSN)
:
(1) Total EITC awarded in tax year __________ available for pass through:
Contribution Date:
Amount:
YYYY
$
$
$
$
$
MMDDYYYY
TOTAL
$
(2) Amount of EITC to be applied to the entity’s liability.
$
(3) Amount of EITC to be passed through to shareholders, members or partners.
$
NOTE: Please answer “yes” to only one of the following questions, as an EITC may be passed through for use by owners in
one tax year only.
o
o
(A) Will the remaining EITC be passed through for use by the owner(s) in the year of contribution?
yes
no
(B) Will the remaining EITC be passed through for use by the owner(s) in the year immediately
o
o
following the year of contribution?
yes
no
Please complete and attach Section II.
I, the undersigned, declare and certify I am a corporate officer, general partner or limited liability company member of the
above-named entity, and I have authority to bind the above-named entity to the terms and conditions of this election.
Signature of Company Official:
Date:
Please remember to sign your form after printing.
MMDDYYYY
Printed Name:
Printed Title or Affiliation to the Entity:
Phone Number:
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