Form Rv-F1319401 - Certificate Of Contribution For Tax Credit - Rural Opportunity Fund
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1Tennessee Department of Revenue
Rural Opportunity Fund
CERTIFICATE OF CONTRIBUTION FOR TAX CREDIT
PART 1 - BUSINESS AND CONTRIBUTION INFORMATION (Completed by Contributor)
Name of financial institution: __________________________________________________________________
Business mailing address: ____________________________________________________________________
Contact person and title: __________________________________ Telephone number: ( ___ ) ____________
Tennessee Franchise and Excise number: ____________________________________________
Tax Year (Check One)
Calendar year
Fiscal year from _______ to _________
Qualified Contribution $ ____________
Date Approved
_______________
Submitted by: __________________________________________
Name of Financial Institution
By: __________________________
____________________________________
_________________
Signature
Print Name and Title
Date
PART 2 - SOUTHEAST COMMUNITY CAPITAL CERTIFICATION (Completed by SCC)
Amount of Eligible Contribution: _________________________
Approved By: __________________________
_________________________________
____________
Signature
Print Name and Title
Date
PART 3 - DEPARTMENT OF REVENUE CERTIFICATION (Completed by Revenue)
Annual Amount of Tax Credit: ___________________________
Approved By: __________________________
_________________________________
____________
Signature
Print Name and Title
Date
RV-F1319401
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