Form Mo-Fpt - Food Pantry Tax Credit Page 2
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1
2Tax Credit (50%)
Date of Contribution (MM/DD/YYYY)
Contribution Amount
Spouse
Yourself
Yourself
Spouse
Yourself
Spouse
___ ___ / ___ ___ / ___ ___ ___ ___
___ ___ / ___ ___ / ___ ___ ___ ___
00
00
00
00
00
00
00
00
___ ___ / ___ ___ / ___ ___ ___ ___
___ ___ / ___ ___ / ___ ___ ___ ___
___ ___ / ___ ___ / ___ ___ ___ ___
___ ___ / ___ ___ / ___ ___ ___ ___
00
00
00
00
___ ___ / ___ ___ / ___ ___ ___ ___
___ ___ / ___ ___ / ___ ___ ___ ___
00
00
00
00
___ ___ / ___ ___ / ___ ___ ___ ___
___ ___ / ___ ___ / ___ ___ ___ ___
00
00
00
00
00
00
00
00
___ ___ / ___ ___ / ___ ___ ___ ___
___ ___ / ___ ___ / ___ ___ ___ ___
___ ___ / ___ ___ / ___ ___ ___ ___
___ ___ / ___ ___ / ___ ___ ___ ___
00
00
00
00
___ ___ / ___ ___ / ___ ___ ___ ___
___ ___ / ___ ___ / ___ ___ ___ ___
00
00
00
00
___ ___ / ___ ___ / ___ ___ ___ ___
___ ___ / ___ ___ / ___ ___ ___ ___
00
00
00
00
___ ___ / ___ ___ / ___ ___ ___ ___
___ ___ / ___ ___ / ___ ___ ___ ___
00
00
00
00
___ ___ / ___ ___ / ___ ___ ___ ___
___ ___ / ___ ___ / ___ ___ ___ ___
00
00
00
00
___ ___ / ___ ___ / ___ ___ ___ ___
___ ___ / ___ ___ / ___ ___ ___ ___
00
00
00
00
___ ___ / ___ ___ / ___ ___ ___ ___
___ ___ / ___ ___ / ___ ___ ___ ___
00
00
00
00
___ ___ / ___ ___ / ___ ___ ___ ___
___ ___ / ___ ___ / ___ ___ ___ ___
00
00
00
00
___ ___ / ___ ___ / ___ ___ ___ ___
___ ___ / ___ ___ / ___ ___ ___ ___
00
00
00
00
___ ___ / ___ ___ / ___ ___ ___ ___
___ ___ / ___ ___ / ___ ___ ___ ___
00
00
00
00
00
00
00
00
___ ___ / ___ ___ / ___ ___ ___ ___
___ ___ / ___ ___ / ___ ___ ___ ___
*Total
00
00
00
00
*If needed, attach a separate sheet and include the total of all contributions here. Enter the total amount on
Form
MO-TC.
I certify the above contributions were made to the food pantry listed above and I am eligible to sign this document.
Signature of Food Pantry Staff Member
Date (MM/DD/YYYY)
___ ___ / ___ ___ / ___ ___ ___ ___
Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.
(Spouse must sign if claiming a
credit(s).)
Signature of Taxpayer
Date (MM/DD/YYYY)
___ ___ / ___ ___ / ___ ___ ___ ___
Signature of Spouse (if applicable)
Date (MM/DD/YYYY)
___ ___ / ___ ___ / ___ ___ ___ ___
This form must be attached to the Miscellaneous Income Tax Credits (Form MO-TC), along with your return.
Form MO-FPT (Revised 12-2014)
Taxation Division
Phone: (573) 751-3220
Visit
P.O. Box 27
Fax: (573) 751-7744
for additional information.
Jefferson City, MO 65105-0027
E-mail:
taxcredit@dor.mo.gov
*14303020001*
14303020001
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Parent category: Financial