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Florida Tax Credit Scholarship Program - Online Application for Tax Credit Allocation for Contributions to Nonprofit Scholarship-Funding Organizations (SFOs)

Enter the appropriate information in the following boxes:

Business Name:

Federal Employer Identification Number (FEIN):

Business Address:

Address (cont):

City:

State:

ZIP:

Contact Person Name:

Contact's Telephone Number:

(999 999-9999)

Contact Person’s Email Address:

Applying for (select one):

Select the nonprofit scholarship-funding organization,SFO, to which the contribution will be made. A separate application is required for each organization.

$Total amount of planned contribution.

*
Indicate the amount of credit allocation for each applicable tax. The sum of the amounts must equal the planned contribution amount entered above.

$

*

Corporate Income Tax

Beginning Date of Tax Year:	mm/dd/yyyy
Ending Date of Tax Year:	mm/dd/yyyy
Extension of Time Already Applied for?	Yes No

$ *

Insurance Premium Tax

Current Calendar Year Prior Calendar Year

$ *

Excise Tax on Malt Beverages
For the Fiscal Year beginning July 1, (YYYY)
Malt Beverage License Number:

$ *

Excise Tax on Wine Beverages
For the Fiscal Year beginning July 1, (YYYY)
Wine Beverage License Number:

$ *

Excise Tax on Liquor Beverages
For the Fiscal Year beginning July 1, (YYYY)
Liquor Beverage License Number:

$ *

Sales and Use Tax due from a Direct Pay Permit Holder
For the Fiscal Year beginning July 1, (YYYY)
Sales Tax Certificate Number: (13 digits)

$ *

Tax on Oil Production
For the Fiscal Year beginning July 1, (YYYY)

$ *

Tax on Gas Production
For the Fiscal Year beginning July 1, (YYYY)

If you file a consolidated Florida corporate income tax return, you must provide the parent corporation's name and FEIN.

Parent Corporation's Name:
Parent Corporation's FEIN:	(999999999)

I understand that section (s.) 1002.395(5)(b)2., Florida Statutes (F.S.), requires the Florida Department of Revenue to provide a copy of any approval or denial it issues with respect to this Application to the nonprofit scholarship-funding organization indicated in this Application.

By typing your name in the space below and submitting this form, you are declaring, under penalties of perjury, that you have read this application and that the facts stated in it are true.

Name:
Title: