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MISSOURI FORM CDTC-770

MISSOURI DEPARTMENT OF ECONOMIC DEVELOPMENT

BENEFIT NUMBER - OFFICE USE ONLY

APPLICATION FOR CLAIMING TAX CREDITS

This application is to be completed by the taxpayer/donor for which a tax credit will be issued. Instructions for completing this form are on the reverse. Please

type or print.

PART I: QUALIFYING PROGRAM

FAMILY DEVELOPMENT ACCOUNT

NEIGHBORHOOD ASSISTANCE PROGRAM

YOUTH OPPORTUNITIES PROGRAM

PART II: TAXPAYER (DONOR) INFORMATION - See instructions.

TAXPAYER NAME - INDIVIDUAL (INCLUDE SPOUSE INFORMATION IF A JOINT RETURN IS FILED) OR BUSINESS NAME (AS LISTED WITH SECRETARY OF STATE'S OFFICE)

FOR BUSINESSES, LIST A CONTACT PERSON

CONTACT EMAIL ADDRESS

CONTACT TELEPHONE #

MAILING ADDRESS

CITY

STATE

ZIP CODE

SOCIAL SECURITY NUMBER

SPOUSE SOCIAL SECURITY NUMBER

BUSINESS FEDERAL ID NUMBER

MISSOURI TAX ID NUMBER

TAXES PAID BY:

□

CALENDAR YEAR

FISCAL YEAR FROM __________________ TO __________________

PART III: TAXPAYER ELIGIBILITY - CHOOSE ONLY ONE ELIGIBILITY STATUS

INDIVIDUAL DONOR

BUSINESS DONOR

□

INDIVIDUAL - YOP AND FDA ONLY

CORPORATION

□

INDIVIDUAL WITH A FARM OPERATION

FINANCIAL INSTITUTION

□

INDIVIDUAL REPORTING INCOME FROM MO RENTAL

PARTNERSHIP - ATTACH PARTNER NAMES, SOCIAL SECURITY

PROPERTY OR ROYALTIES

NUMBERS, AND PERCENTS OF OWNERSHIP

□

INDIVIDUAL REPORTING INCOME FROM A SOLE

S-CORPORATION - ATTACH SHAREHOLDER NAMES, SOCIAL

PROPRIETORSHIP

SECURITY NUMBERS, AND PERCENTS OF OWNERSHIP

□

INDIVIDUAL REPORTING INCOME FROM A PARTNERSHIP,

LIMITED LIABILITY CORP - ATTACH MEMBER NAMES, SOCIAL

S-CORPORATION, OR LIMITED LIABILITY CORP (LLC)

SECURITY NUMBERS, AND PERCENTS OF OWNERSHIP

□

INSURANCE COMPANY

PART IV: TYPE OF CONTRIBUTION AND VALUE

DATE OF CONTRIBUTION

TYPE OF CONTRIBUTION

VALUE

MONTH/DAY/YEAR

□

CASH; WERE ANY GOODS AND/OR SERVICES RECEIVED?

YES

□

STOCKS (VALUED BETWEEN HIGH AND LOW ON THE DATE OF TRANSFER FROM DONOR

INTO NONPROFIT'S BROKERAGE ACCOUNT)

□

IN-KIND (VALUED AS LESSER OF COST TO DONOR OR FAIR MARKET VALUE)

□

WAGES PAID TO PARTICIPATING YOUTH - YOP ONLY

PART V: TAXPAYER CERTIFICATION AND NOTARIZATION (TO BE SIGNED IN NOTARY'S PRESENCE)

I have examined the above application and confirm, to the best of my knowledge, information, and belief, that the above information is true and correct. Further, if operating as a business in

Missouri, I declare that I do not knowingly employ illegal aliens and have complied with federal law (8 U.S.C. 1324A), which requires examination of the appropriate documents to verify employment

eligibility. I understand that if found to have employed an illegal alien in Missouri and did not, for that employee, examine the documents required by federal law, that I shall be ineligible for any

state-administered or subsidized tax credit, tax abatement, or loan for a period of five years following any such finding.

TAXPAYER SIGNATURE

NOTARY PUBLIC EMBOSSER OR BLANK INK RUBBER

STATE

COUNTY (OR CITY OF ST. LOUIS)

STAMP SEAL

SUBSCRIBED AND SWORN BEFORE ME, THIS

USE RUBBER STAMP IN CLEAR AREA BELOW

DAY OF

YEAR

NOTARY PUBLIC SIGNATURE

MY COMMISSION EXPIRES:

NOTARY PUBLIC NAME TYPED OR PRINTED

PART VI: CONTRIBUTION VERIFICATION BY PROJECT DIRECTOR

APPROVED ORGANIZATION NAME

PROJECT NUMBER

I have examined this application and all attachments and believe it to be an accurate description of the contribution received by our organization for the purpose of carrying

out the approved project.

PROJECT DIRECTOR NAME PRINTED/TYPED

PROJECT DIRECTOR SIGNATURE

DATE

THIS FORM MUST BE SUBMITTED TO DED WITHIN 12 MONTHS FROM THE DATE OF DONATION TO QUALIFY FOR A TAX CREDIT.

(03/2014)