Form DR-116000 Application for Tax Credit Allocation for Contributions to Nonprofit Scholarship Funding Organizations (SFOs) R.07/12

(For the current Calendar Year) (s 212 183 F S ) 1 Contribution to nonprofit SFO 1 Deductions for assessments made pursuant to s 440 51 F S (workers compensation administrative assessments) 2 Credit Carry Forward 2 Credits for taxes paid under ss 175 101 and 185 08 F S (firefighters and police officers pension trust funds) and 3 Credits for income tax paid under Chapter 220 F S and the salary credit allowed under s 624 509(5) F S as these are limited by s 624 509(6) F S (the sixty five percent limitation) Amount of contribution Beginning Date of Tax Year: Ending Date of Tax Year: Contributor s FEIN Contributor s name Contributor's license number issued by the Corporate Income Tax (Chapter 220 F S ) Corporate income taxpayers (Chapter 220 F S ) Date of contribution Division of Alcoholic Beverages and Tobacco Excise Tax on Liquor Beverages (s 565 12 F S ) Excise Tax on Malt Beverages (s 563 05 F S ) Excise Tax on Wine Beverages (s 564 06 F S ) Florida oil and gas production taxpayers (ss 211 02 and 211 025 F S ) For the Fiscal Year beginning July 1 and ending June 30 For the Fiscal Year beginning July 1 and ending June 30 For the Fiscal Year beginning July 1 and ending June 30 Insurance Premium Tax (s 624 509 F S ) Insurance premium taxpayers (s 624 509 F S ) Name of nonprofit SFO Please provide your Liquor Beverage License Number: Please provide your Malt Beverage License Number: Please provide your Wine Beverage License Number: Sales and Use Tax due from a Direct Pay Permit Holder (s 212 183 F S ) Sales Tax Certificate Number Signature of officer owner or partner Date Tax on Gas Production (s 211 025 F S ) Tax on Oil Production (s 211 02 F S ) Taxpayers who pay excise tax on liquor wine and malt beverages (ss 563 05 564 06 and 565 12 F S ) Taxpayers who pay sales tax under a direct pay permit (Under sections [ss ] 211 0251 212 1831 220 1875 561 1211 624 51055 A copy of the certificate of contribution from each nonprofit SFO must be attached to the return when claiming the credit All other requirements of s 1002 395 F S must be met to claim this credit Amount to be credited against each tax (The sum of the amounts by tax cannot exceed the total planned contribution or credit carry forward above ): An officer or authorized representative of the nonprofit SFO will sign the certificate You must attach a copy of the certificate(s) of contribution to your tax return when filed; or for sales tax submit a copy of the certificate to the Department before claiming the credit and 1002 395 Florida Statutes [F S ]) Application for Tax Credit Allocation for Contributions to Business name Choose one of the two options below You must complete a separate application for each nonprofit SFO and for each separate beverage license for which a separate return is filed For credit carry forward purposes a separate application for each nonprofit SFO is not required City State ZIP Contact person Contact s telephone number Contributions must be monetary and must be made to eligible nonprofit SFOs The Department of Education establishes the eligibility of the nonprofit SFOs A list of nonprofit SFOs is available from the Department of Education s Internet site at www floridaschoolchoice org/ Their phone number is 800 447 1636 Contributions to a nonprofit SFO are not payments of estimated tax or installment payments of tax Taxpayers must make installment payments to the Department of Revenue in accordance with s 220 34 F S and Rule 12C 1 034 F A C for corporate income tax; s 624 5092 F S and Rule 12B 8 001 F A C for insurance premium tax; and s 212 11 F S and Rule 12A 1 056 F A C for sales and use tax Corporate Income Tax Direct pay permit holders must provide their sales tax certificate number below: DR 116000 DR 116000 Effective 01/13 Enter the name of the Department of Education approved nonprofit SFO you are planning to contribute Example 1 A corporate income taxpayer or insurance premium taxpayer applying for a credit allocation for its tax year beginning on January 1 2012 could submit an application between January 3 2012 and December 31 2012 assuming the annual allocation is not exhausted before the time of application In this example you must contribute to the nonprofit SFO between January 1 2012 and December 31 2012 Example 2 A corporate income taxpayer applying for a credit allocation for its tax year beginning on July 1 2012 could submit an application between January 3 2012 and June 30 2013 assuming the annual allocation is not exhausted before the time of application In this example you must contribute to the nonprofit SFO between July 1 2012 and June 30 2013 Example 3 A sales taxpayer or oil and gas production taxpayer applying for a credit allocation could submit an application between January 3 2012 and June 30 2013 assuming the annual allocation is not exhausted before the time of application In this example you must contribute to the nonprofit SFO between July 1 2012 and June 30 2013 and the credit can be claimed after the contribution is made and before June 30 2013 For any credit amount that is not used before June 30 2013 an application can be submitted beginning July 1 2013 for approval to carry forward the unused credit to be used in the new state fiscal year An unused credit cannot be carried forward more than 5 years Example 4 A taxpayer who pays excise tax on liquor wine and malt beverages applying for a credit allocation could submit an application between January 3 2012 and June 30 2013 assuming the annual allocation is not exhausted before the time of application In this example you must contribute to the nonprofit SFO between July 1 2012 and June 30 2013 and the credit can be claimed after the contribution is made and before June 30 2013 For any credit amount that is not used before June 30 2013 an application can be submitted beginning July 1 2013 for approval to carry forward the unused credit to be used in the new state fiscal year An unused credit cannot be carried forward more than 5 years Excise Tax on Liquor Wine and Malt Beverages Federal Employer Identification Number (FEIN) Florida Administrative Code Florida Department of Revenue For corporate income tax and insurance premium tax applications can be submitted beginning on the first business day in January for contributions to be made in tax years that begin in the same calendar year For the excise tax on liquor wine and malt beverages applications can be submitted beginning on the first business day in January for contributions to be made in the state fiscal year beginning the following July 1 For the oil and gas production tax and sales tax paid under a direct pay permit applications can be submitted beginning on the first business day in January for contributions to be made in the state fiscal year beginning the following July 1 If the credit is not fully used in any applicable tax year (for corporate income or insurance premium tax) or state fiscal year (for excise tax on malt beverages wine and liquor; oil and gas production tax; or sales tax) application may be made to obtain approval to carry forward the unused credit in a subsequent year An unused credit cannot be carried forward more than 5 years The credit cannot be conveyed assigned or transferred to another entity unless all of the assets of the taxpayer are conveyed assigned or transferred in the same transaction If the nonprofit SFO listed on the approval letter is unable to accept a contribution or part of a contribution because of its obligations under s 1002 395 F S and it provides a written statement declining the contribution the taxpayer may make the contribution or partial contribution to another eligible nonprofit SFO The taxpayer should keep the written statement for its records to support the credit claimed Contributions must be made during the year specified in the approval letter If you file a consolidated Florida corporate income tax return you must provide the parent corporation s name and FEIN Instructions for Completing Form Insurance Premium Tax Mailing address Nonprofit Scholarship Funding Organizations (SFOs) Oil and Gas Production Tax Once you receive written confirmation and approval for the credit allocation from the Department you are expected to make such contribution within the tax year or state fiscal year for which the credit allocation was approved One hundred percent of an eligible contribution is allowed as a credit against any tax due under s 624 509 F S after deducting from such tax: One hundred percent of an eligible contribution is allowed as a credit against any tax due under ss 563 05 564 06 or 565 12 F S except excise taxes imposed on wine produced by manufacturers in this state from products grown in this state The amount of the credit taken may not exceed ninety percent of the tax due on the return A copy of the certificate of contribution from each nonprofit SFO must be attached to the return when claiming the credit One hundred percent of an eligible contribution is allowed as a credit Before a credit can be claimed on a sales and use tax return the taxpayer must submit a copy of the certificate of contribution from each nonprofit SFO to: One hundred percent of an eligible contribution is allowed as a credit but the amount of the credit taken may not exceed fifty percent of the tax due on the return A copy of the certificate of contribution from each nonprofit SFO must be attached to the return when claiming the credit One hundred percent of an eligible contribution is allowed as a credit The credit granted must be reduced by the resulting decrease in federal income tax when considering this credit and the overall impact it has on the federal income tax due The amount taken as a credit for the taxable year must be added back to taxable income A copy of the certificate of contribution from each nonprofit SFO must be attached to the return when claiming the credit Parent corporation Parent corporation s FEIN PO Box 6609 Program Guidelines Program Information R 07/12 R 07/12 Revenue Accounting Rule 12 29 003 Sales and Use Tax Due From a Direct Pay Permit Holder Tallahassee FL 32314 6609 The allocation of each state fiscal year s allotted amount begins on the first business day in January The Department will send you written correspondence within 10 working days of receiving your application We will either approve an amount of tax credit allocation or explain why a credit allocation could not be approved The following taxpayers may participate in the Florida Tax Credit Scholarship Program for contributions to nonprofit SFOs: The letter granting approval of the credit allocation will indicate the time frame in which the contribution must be made and express that the credit is contingent upon an eligible contribution being made and accepted by the nonprofit SFO Total amount of planned contribution or credit carry forward: $ Under penalty of perjury I declare that I have read this application form and that the facts stated in it are true Upon receiving a contribution a nonprofit SFO will issue a certificate of contribution to the taxpayer This certificate will contain the following information: We will accept applications until the allotted amount is reached or until the end of the applicable state fiscal year or tax year (for corporate income and insurance premium tax) whichever occurs first Who May Apply? Within 10 working days the Department of Revenue will respond with specific instructions about how to claim the credit on your return You may apply for this credit allocation using the Department s Internet site at www myflorida com/dor Once you complete the online application you will receive a confirmation number that you can print out The screen will display the information entered and confirm receipt of the electronic application for credit allocation or credit carry forward You must complete a separate application for each nonprofit SFO and for each separate beverage license for which a separate return is filed For credit carry forward purposes a separate application for each nonprofit SFO is not required You must specify in the application each tax for which you request a credit and include the applicable tax year for corporate income tax or state fiscal year for all the other taxes except Insurance Premium Tax which is always the current calendar year