Form IT-QEE-TPi

This form is to authorize CICM.INC to submit your application for participation in the Qualified Education Expense Credit for the Georgia Department of Revenue. Please complete and submit this form. All applications will be submitted to the GA Dept. of Revenue by CICM on the first working day of the next calendar year.

Taxpayer Name

First Name

Last Name

Taxpayer SSN

No Dashes (-) Please

Spouse's Name

First Name

Last Name

Spouse's SSN

No Dashes (-) Please

New GA Filer

Is this the first calendar year for which you are filing income tax with the State of Georgia?

Yes

How are you filling?

Are you a Business Owner?

Are you an Individual Owner or Part owner or spouse of an Owner of a S-Corp, LLC, partnership, or C-Corp?

I am a Business Owner

I am the Spouse of a Business Owner

I am NOT a Business Owner or the Spouse of a Business Owner

Email Address

Phone Number

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contribution Amount

Tax Credit Limit Individual - $2,500.00 Married Filling Separately - $2,500.00 Married Filling Jointly - $5,000.00 Individual Owner of S-Corp, LLCs, or Partnerships - $25,000.00 Taxpayer and Spouse Owner of S-Corp, LLCs, or Partnerships - $50,000.00 ($25,000.00 each) C-Corp - 75% of their Liability Note: This amount is not a commitment.

Designated School

If left blank, your tax dollars will be applied to scholarship students at our partner school, Friendship Christian School.

Terms and Conditions

Please use this form as my authorization to include me in the SSO program annually.

I Agree

Signature

Type full name

Date

YYYY

Applying for Corporation? (Leave blank if not)

C-Corporation

S-Corporation

Corporation Name

Please fill in your corporation name if you are applying as a corporation only.

Federal ID (Corporation Only)