Indiana Department of Revenue
Form NC-10
Neighborhood Assistance
State Form 49176 (R2/7-05)
Tax Credit Application
(File with the recipient organization participating in the Neighborhood Assistance Program)
Contributor Information (To be completed by the contributor and the qualified Neighborhood Assistance Organization)
Name of contributor
Social Security or Federal Identification Number
Address
Telephone number
City
State
Zip Code
Contributor’s tax year ending
Type of income tax return filed by contributor.
Check One:
Individual Form IT-40
Fiduciary Form IT-41
Partnership Form IT-65
Nonprofit Form IT-20NP
Corporation Form IT-20
S Corporation Form IT-20S
Financial Institution Form FIT-20
Credit Computation
(Contributor must sign below, provide proof of payment and/or a statement of the value of all services and materials donated)
Date of contribution
Program Number
1. Amount of contribution. Indicate type:
Cash
Service
Property ...........................................................................
1. $
2. Multiply line 1 by 50% (x .50) .........................................................................................
2. $
3. Tentative amount of credit (lessor of line 2 or $25,000) ...........................................................
3. $
Signature of contributor
Recipient Organization Information
Name of organization
Indiana Taxpayer Identification Number or Federal
Identification Number
35-0868078
Headwaters Counseling
Address
City
State
Zip Code
46807
IN
Fort Wayne
2712 S. Calhoun St.
Certification of Contribution for Donation to Neighborhood Assistance Program
I certify that the contributor donated the amount on line 1 to the Neighborhood Assistance Program and that the information stated is true, correct
and complete.
Executive Director
260-744-4326
Signature of neighborhood assistance organization officer
Title
Telephone Number
Date
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