Indiana Department of Revenue Form NC-10 Neighborhood Assistance Tax Credit Application State Form 49176 (R2/7-05) (File with the recipient organization participating in the Neighborhood Assistance Program) Contributor Information (To be completed by the contributor and the qualified Neighborhood Assistance Organization) Name of contributor Social Security or Federal Identification Number Address Telephone number City State Type of income tax return filed by contributor. Zip Code Contributor’s tax year ending Check One: Individual Form IT-40 Fiduciary Form IT-41 Partnership Form IT-65 Nonprofit Form IT-20NP Corporation Form IT-20 S Corporation Form IT-20S Financial Institution Form FIT-20 Credit Computation (Contributor must sign below, provide proof of payment and/or a statement of the value of all services and materials donated) Date of contribution Program Number 1. Amount of contribution. Indicate type: Cash Service Property ........................................................................... 1. $ 2. Multiply line 1 by 50% (x .50) ......................................................................................... 2. $ 3. Tentative amount of credit (lessor of line 2 or $25,000) ........................................................... 3. $ Signature of contributor Recipient Organization Information Name of organization Address Indiana Taxpayer Identification Number or Federal Identification Number City State Zip Code Certification of Contribution for Donation to Neighborhood Assistance Program I certify that the contributor donated the amount on line 1 to the Neighborhood Assistance Program and that the information stated is true, correct and complete. Signature of neighborhood assistance organization officer Title Telephone Number Date American LegalNet, Inc. www.FormsWorkflow.com Instructions for Filing Form NC-10 (7/05) Neighborhood Assistance Tax Credit Application Instructions for Recipient Organizations Form NC-10 must be filed by a taxpayer (including any S corporation, partnership, limited liability company, or individual) who makes a contribution and wishes to claim credit for the donation made to a qualified organization participating in the Neighborhood Assistance Program (NAP). The credit can be applied against a taxpayer’s Indiana adjusted gross income tax, or the financial institution tax. 50% of the amount contributed is eligible for the tax offset credit up to a maximum of $25,000. Form NC-10 is distributed by the Indiana Housing and Community Development Authority (IHCDA) through the Neighborhood Assistance Program. The neighborhood assistance organization must fill in the recipient organization information sections of Form NC-10. List the neighborhood assistance organization’s Federal Identification or Indiana taxpayer identification number (TID) and/or program number. An officer or delegate of the organization must verify receipt of each contribution by signing the certification section of the form. Applications are filed through the neighborhood assistance organization. Each organization must have an approved program number from the IHCDA before a contribution qualifies for preapproval. The State of Indiana is limited to granting a total of $2,500,000 in Neighborhood Assistance Program tax credits per state fiscal year. Applications for credit will be considered in the chronological order as received by the Department of Revenue. For further instructions, refer to Income Tax Information Bulletin #22, issued by the Department of Revenue. Completing Form NC-10 Complete the identification sections at the top of the form using the legal name of the contributor and the same tax identification number used for federal purposes. Check the type of tax return to be filed by the contributor (be sure to indicate the current tax year ending date). Tax Credit Computation and Certification Line 1: Enter the amount and kind of contribution made to the neighborhood assistance organization having a qualified tax credit program. The computation is based on contributed amounts from $100 up to $50,000. Credit is limited to the lesser of: fifty percent (50%) of the amount contributed, the state income tax due, or twentyfive thousand dollars ($25,000). Line 2: Enter the amount of your contribution multiplied by 50% (.50). This is the amount eligible for NAP tax credit, subject to the maximum credit limit and your income tax liability after applying other nonrefundable credits for the tax year of the contribution. Line 3: Enter the lesser of line 2 or $25,000. This tentative approved credit is available to offset only the annual state income tax or franchise tax liability. There is no carry over of unused credit to other taxable years. It is the responsibility of the contributor/taxpayer to claim the approved credit for the tax year in which the donation was made. The credit application must be signed to be considered valid. If left unsigned, the application will be returned for signature. Proof of payment (copy of check, receipt from the neighborhood assistance organization, etc.) must be attached to this application. It is the recipient organization’s responsibility to file NC-10 form with the Indiana Housing and Community Development Authority. File completed NC-10 form with the quarterly report form on assigned due dates. Send to the Neighborhood Assistance Program, 30 South Meridian, Suite 1000, Indianapolis, Indiana 46204. Applications filed with these state agencies are submitted to the Indiana Department of Revenue for a final determination. The Department will accept a properly completed contributor application and certification as proof of cash contributions. When the tax credit application is approved, Form NC-20 will be mailed to contributor/taxpayer. The approved credit is available to offset only the annual state income tax liability. County income taxes may not be reduced. For purposes of this limitation, state income tax due is first reduced by any other nonrefundable credit according to I.C. 6-3.1-1-2, such as credit for taxes paid to other states and the college contribution credit, before the NAP tax credit is applied. There is no provision to carry back, carry forward, or refund any unused portion of the credit. The Department will return the Form NC-20 with one of the following indications: Approved -- Your credit request has been approved for the amount indicated on Form NC-20. Attach the approved Form NC-20 to the Indiana tax return to support the claim. If a pass-through entity made a contribution does not have a state income tax liability, it must report the prorata share of the approved credit on information Schedule IN K-1. (Members of pass-through entities must attach a copy of Schedule IN K-1 to claim their allotted share of this credit.) Any excess credit on their return may not be refunded or carried over. Disapproved -- Your tax credit request is not allowed. If the tax credit application is disapproved, a letter is sent to explain the reason for denial. For all inquiries about the Neighborhood Assistance Program call: the Indiana Housing and Community Development Authority at 317-232-7777 or 1-800-872-0371 outside Indianapolis. To qualify for the credit, contributions other than cash must be contemplated by the program proposal submitted by the organization for approval. Any in kind contributions and services must be supported with invoices or other documents showing proof of costs to the donor. Cost of personnel on loan or the cost of time of an individual donor, contributed to render expertise and assistance, must be fully supported and are allowed to the extent the Internal Revenue Service rules for charitable deductions are applied. American LegalNet, Inc. www.FormsWorkflow.com