Education Improvement Scholarships Tax Credits Program - Preauthorization Form (Revised 6/2013)

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Preauthorization
Virginia Department of Education
Form
Education Improvement Scholarships Tax Credits Program
Keep this Preauthorization Form for your records.
You are not required to provide an approved Preauthorization Form to the scholarship foundation when making a donation.
Use this form to request preauthorization for a specified tax credit amount under the Education Improvement Scholarships Tax Credits Program,
authorized by Section 58.1-439.25 et seq., Code of Virginia.
If the preauthorization request is approved by the Department of Education, the donor will receive, via U.S. Mail, a Preauthorization Notice that
is to be completed by the donor and the scholarship foundation, and submitted along with the monetary or marketable securities donation. The
donation(s) must be made and the scholarship foundation(s) must successfully submit the completed Preauthorization Notice form(s) to the
Department within 180 days of the date of the Preauthorization Notice. Any preauthorized amounts not successfully submitted for credit within
this time frame become void. Donors who use all of their preauthorized tax credits or whose preauthorized tax credits become void must file
another Preauthorization Form with the Department in order to be preauthorized for additional tax credits. For additional information, please
refer to the instructions on page 2 of this form.
Part I – Preauthorization Request (To be completed by the donor.)
Donor’s Name:
Donor’s SSN or FEIN if a business:
Address:
City, Town or Post Office:
State:
ZIP Code:
Name of County or City in which you reside:
Phone Number:
City
OR County
1.
Check One:
Individual
Sole Proprietor
S Corporation
C Corporation
Partnership
Limited Liability Company (LLC)
Other
_______________
If the donor is a business, provide the following information:
______________________________
_______________
Contact Name
Phone Number
2.
Tax Credit Calculation:
a. Enter the total amount of all donations to be made and submitted for tax credits
$
___________
within 180 days of the Preauthorization Notice date.
(For individuals, the minimum donation for issuance of tax credits is $500 in a taxable year,
and the maximum aggregate donations for issuance of tax credits are $125,000 in a
taxable year. There are no limitations for businesses. An individual that has already been
issued tax credits for donations of $500 or more to a scholarship foundation can be issued
tax credits for additional donations to the same scholarship foundation that are less than
$500, provided that the additional donations are made in the same taxable year.)
b. Enter the total amount of tax credits being requested.
$
___________
(Multiply the total of all donations above by 65% (.65), unless subject to limitation above.)
c. If you are an individual, have you been issued one or more tax certificates by the
Yes
No
OR
Department for other donations made during the same calendar year?
3.
Declaration:
I declare that this form is, to the best of my knowledge and belief, a true, correct and complete application, and that I have made myself
aware of the requirements for this tax credit as prescribed by the Virginia Department of Education.
__________
__________________________________________
_______
Printed Name
Signature
Date
If a scholarship foundation is filing the Preauthorization Form on behalf of the donor, then it must submit the form using the Department’s secure
Web-based system provided on the Department’s Web site.
Otherwise, the donor or authorized representative must submit the form via U.S. Mail to: Virginia Department of Education, Accounting
Office, Attn: Scholarship Tax Credit Program, P.O. Box 2120, Richmond, VA 23218-2120.
Part II – Preauthorization Approval (To be completed and signed by the Virginia Department of Education.)
The above preauthorization request was received by the Department of Education on ____ / ____ / ____ at ______________________, and is:
Approved – Amount of Preauthorized Tax Credits:
$__________________
Waitlisted – Amount of Tax Credits that are Waitlisted:
$__________________ (See instructions.)
_______________________________________________________
_________________
Authorized by the Virginia Department of Education
Date
Virginia Department of Education
Page 1 of 2
Form Revised 6/2013

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