Form DR-116100 Application for Rescindment of Tax Credit Allocation for Contributions to Nonprofit Scholarship Funding Organizations (SFOs) R.07/11

Corporate Income Tax (Chapter 220 F S ) 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 ) Insurance Premium Tax (s 624 509 F S ) Sales Tax Paid by a Direct Pay Permit Holder (s 212 183 F S ) 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on Gas Production (s 211 025 F S ) Tax on Oil Production (s 211 02 F S ) (1) You have claimed the credit amount to be rescinded on a previously filed tax return (2) The allocation year is closed for all taxpayers The allocation for a particular year is closed for all taxpayers on November 30th of the following year For example the allocation year beginning January 1 2010 for the state fiscal year beginning July 1 2010 closes for all taxpayers on November 30 2011 regardless of whether the annual allotment has been reached because there are no more tax years remaining open that began in calendar year 2010 as of November 30 2011 (Under sections [ss ] 211 0251 212 1831 220 1875 561 1211 624 51055 Amount to be rescinded by tax (The sum of the amounts by tax cannot exceed the total amount you wish to rescind above ) (The amount to be rescinded for each tax cannot exceed the amount allocated to that tax on the original application): and 1002 395 Florida Statutes [F S ]) Application for Rescindment of Tax Credit Allocation for Contributions to Nonprofit Scholarship Funding Organizations (SFOs) Applications for rescindment can be made on the Department s Internet site: dor myflorida com/dor Once you have entered the requested information a confirmation screen with a confirmation number will appear This screen will display the information entered and confirm receipt of the electronic application for rescindment You can print this screen or simply record the confirmation number to prove that you submitted an application for rescindment Business name City State ZIP Confirmation number of original credit allocation application Contact person Contact s telephone number DR 116100 Effective 01/12 Enter the amount you wish to rescind $ Enter the name of the SFO the credit was originally approved for: Federal Employer Identification Number (FEIN) Florida Administrative Code If included in a consolidated Florida corporate income tax return provide: If you don't have your original confirmation number contact the Revenue Accounting section at 850 617 8586 Instructions for Completing Form DR 116100 Mailing address Original amount of planned contribution $ Parent Corporation s FEIN R 07/11 Rule 12 29 003 Under penalty of perjury I declare that I have read this application form and that the facts stated in it are true We will approve the rescindment unless: Within ten working days of receipt of an application we will send written correspondence regarding the approved amount or the reason we could not approve the rescindment You may apply to the Department for rescindment of all or part of a previously approved credit allocation for a contribution to an SFO You must submit a separate application for the rescindment of each previously approved credit allocation