Form Mo-Atc - Adoption Tax Credit Claim
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Department Use Only
Missouri Department of Revenue
(MM/DD/YY)
Form
Adoption Tax Credit Claim
MO-ATC
Beginning
Ending
Taxable Year
(MM/DD/YY)
(MM/DD/YY)
Adoptive
Social Security
Father’s
Name
Number
Adoptive
Social Security
Mother’s
Name
Number
Business
Name
Missouri Tax I.D.
Federal Employer
Number
I.D. Number
NAICS Code
Charter
(if applicable)
Number
Address
City
Telephone
Number
State
ZIP
Tax Type
Individual
Corporation
Non-Profit
Other
Name of
Social Security
Adopted
Number
Child
(If Available)
State or
Birthdate of
Age of
Country of
Child
Child
Origin
(MM/DD/YY)
Date Adoption
Date Child
Became Final
Was Placed
(MM/DD/YY)
(MM/DD/YY)
1) Was the child a resident of Missouri prior to assignment? ........................................................................................................
Yes
No
2) Did the adoptive parents have legal custody prior to the assignment? .....................................................................................
Yes
No
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.
Select this box if you have a statement from the physician.
*14300010001*
14300010001
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Parent category: Financial