Form Mo-Scc - Shared Care Tax Credit

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FORM
MISSOURI DEPARTMENT OF REVENUE
MO-SCC
TAXATION DIVISION
SHARED CARE TAX CREDIT
(REV. 10-2012)
This form must be completed and sent with Form MO-TC and Form MO-1040, Individual Income Tax Return.
This tax credit is nonrefundable.
A shared care member registered with the Division of Senior and Disability Services, Missouri Department of Health and Senior Services, may
be eligible for a tax credit equal to his or her Missouri tax liability or $500, whichever is less, to offset the cost of caring for an elderly person.
To be eligible for the shared care tax credit, the following requirements must be met.
v The caregiver must care for an elderly person, age sixty or older, who:
v is physically or mentally incapable of living alone, as determined and certified by his or her licensed physician or by the
Division of Senior and Disability Services, Missouri Department of Health and Senior Services staff; and
v requires assistance with activities of daily living to the extent that without care and oversight at home would require placement
in a facility; and
v under no circumstances, is able or allowed to operate a motor vehicle; and
v does not receive funding or services through Medicaid or social services block grant funding.
v The caregiver must live in the same residence to give protective oversight for an aggregate of more than six months per tax year.
v The caregiver must not receive monetary compensation for providing care for the elderly person.
REGISTERED CAREGIVER
NAME
SOCIAL SECURITY NUMBER
__ __ __ - __ __ - __ __ __ __
ADDRESS
TELEPHONE NUMBER
(__ __ __) __ __ __ - __ __ __ __
I attest that I have read the above and I meet the eligibility requirements listed above for the shared care tax credit. I declare under penalties of perjury that I
employ no illegal or unauthorized aliens as defined under federal law and that I am not eligible for any tax exemption, credit or abatement if I employ such aliens.
SIGNATURE
ELDERLY RECIPIENT OF CARE
NAME
SOCIAL SECURITY NUMBER
__ __ __ - __ __ - __ __ __ __
ADDRESS
DATE OF BIRTH (MM/DD/YYYY)
__ __ / __ __ / __ __ __ __
LIST THE IDENTITY OF ANY OTHER STATE OR FEDERAL PROGRAM UTILIZED TO OFFSET THE COST OF THIS INDIVIDUAL’S CARE
TO QUALIFY FOR A TAX CREDIT ONE OF THE FOLLOWING CERTIFICATIONS MUST BE COMPLETED
Physician Certification
I certify due to the physical or mental conditions described below, the recipient, listed above is incapable of living alone and must acquire
necessary home care to avoid placement in a care facility.
Description of physical or mental condition (include description of the care assistance needed): _________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Signature_________________________________________________
Division of Senior and Disability Services, Missouri Department of Health and Senior Services Certification
I certify due to the physical or mental conditions described below, the recipient, listed above is incapable of living alone and must acquire
necessary home care to avoid placement in a care facility.
Description of physical or mental condition (include description of the care assistance needed): __________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Signature_________________________________________________
NAME OF AGENT OR CONTACT
ADDRESS
PHONE NUMBER
(__ __ __) __ __ __ - __ __ __ __
MO-SCC (10-2012)
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