Application for Rescindment of Tax Credit Allocation for Contributions to Nonprofit Scholarship Funding Organizations (SFOs)
(Under sections [ss.]211.0251, 212.1831, 220.1875, 561.1211, 624.51055 and 1002.395, Florida Statutes,[F.S.])
Enter the appropriate information in the following boxes:
| Business Name:
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| Federal Employer Identification Number (FEIN):
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| Mailing Address:
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| Address (cont):
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| City:
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| State:
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| Zip Code:
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| Contact Person:
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| Contact's Telephone Number:
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(999 999-9999)
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| Contact Person’s Email Address :
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| If included in a consolidated Florida corporate income tax return, provide:
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| Amount you wish to rescind:
$
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| Enter the amount(s) to rescind based on the tax type. (The sum of the amounts by tax cannot
exceed the total amount you wish to rescind above. The amount to be rescinded for each tax
cannot exceed the amount allocated to that tax on the original application.)
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| $ Corporate Income Tax (Chapter 220, F.S.)
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| $ Insurance Premium Tax (s. 624.509, F.S.)
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| $ Excise Tax on Malt Beverages (s. 563.05, F.S.)
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| $ Excise Tax on Wine Beverages (s. 564.06, F.S.)
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| $ Excise Tax on Liquor Beverages (s. 565.12, F.S.)
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| $ Sales and Use Tax due from a Direct Pay Permit Holder (s. 212.183, F.S.)
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| $ Tax on Oil Production (s. 211.02, F.S.)
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| $ Tax on Gas Production (s. 211.025, F.S.)
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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.
I understand that section (s.) 1002.395(5)(f), Florida Statutes (F.S.), requires the Florida Department of Revenue
to provide copy of any approval of denial it issues with respect to this application for rescindment to the nonprofit
scholarship-funding organization indicated on the associated application for an allocation of credit.
Name:
Title:
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