Appendix 1

Application for Educational Improvement Tax Credits

Name	CEO
CEO Title:	Address:
City:	State:
Zip Code:	FEIN:
Contact Name:	Contact Title:
Phone Number:	Fax Number:
Business SIC/NAICS Code:	Description of Business Activity:
Business Tax Year:	Corporate File Box Number:

Amount of tax credits requested: $_________ Total Amount of contributions made:

To a scholarship organization: $__________To an Educational improvement Organization: __________

Organization(s) to receive contributions (optional): ST. THERESA SCHOOL

If the contribution will be personal property or services, please attach a separate page describing the property or service and appropriate information establishing the value of the contribution.

Will the same amount of contribution be made for two consecutive tax years: YES NO

Please identify the taxes to which the business is subject (check all that apply).

Tax	Applicable to Business
Corporate Net Income Tax
Capital Stock Franchise Tax
Bank & Trust Company Shares Tax
Title Insurance Company Shares Tax
Insurance Premiums Tax
Mutual Thrift Institutions Tax

I hereby certify that all information contained herein is true and correct to the best of my knowledge. I also acknowledge that tax credits will be awarded only for contributions made to organizations listed by the Department and that contributions must be made within 60 days after the date of the notification letter from the Department. Further more, I acknowledge that if I knowingly make a false statement to obtain tax credits, I (company, entity and signer) may be subject to criminal prosecution.

Signature____________________________________ Date: __________________________________

Print Name___________________________________ Title: ___________________________________