M
ISSOURI DEPARTMENT OF SOCIAL SERVICES
OMESTIC VIOLENCE SHELTER TAX CREDIT
PPLICATION FOR CLAIMING TAX CREDITS
D
A
INSTRUCTIONS
1. Taxpayer or business name should be the complete name submitted on annual income tax returns. If filing Missouri
joint income tax return, both spouses’ names must be listed.
2. Provide the complete address and telephone number of the taxpayer(s) or business.
3. Taxpayer identification is either the social security number of the individual taxpayer(s) or the business federal
identification number (FEIN). Social security number(s) must be provided for all taxpayers listed in item #1.
4. Amount of donation is the total funds received or the total value of the donation after the fair market value of any benefit
received is deducted (the eligible tax credit will be 50% of this amount).
5. Amount of tax credit is equal to 50% of the donation.
6. Date of the donation.
7. Taxpayer type - place an (X) in the appropriate box and provide supporting documentation indicated if applicable.
Supporting Documentation:
Partnerships, S Corporations and LLC’s please provide a list of all shareholder names; social security numbers, and
percentage of ownership.
Charitable organizations applying for tax credits under Section 135.550, RSMo, must provide:
• proof the organization is exempt from federal income tax (copy of federal tax exemption certificate), and
• proof of business activities that are unrelated to its charitable activities of which Missouri unrelated business taxable
income, if any, would be subject to the state income tax imposed under chapter 143, RSMo (i.e. most recent
Missouri State Income Tax Return). If the unrelated business activities do not generate Missouri business taxable
income, an Executive Officer of the organization must provide an attestation indicating the organization’s unrelated
business activities do not generate taxable business income but if there were taxable business income, that income
would be subject to the state tax imposed under chapter 143, RSMo (attach the Charitable Organization Attestation
Form to the application).
8. Identify the Domestic Violence Shelter receiving the donation.
9. Provide the organization’s physical address in addition to a P.O. Box (if applicable).
10. Provide the organization’s telephone.
11. Provide the organization’s contact person’s name.
12. Identify the type of donation made and provide supporting documentation.
Verifying documentation must be attached to the tax credit application. The type of documentation required will depend
on the type of donation. Required documentation includes the following:
• Cash – legible receipt from the domestic violence shelter which indicates the name and address of the
organization; name, address and telephone number of the contributor; amount of the cash donation and the date
the contribution was received; signature of a representative of the domestic violence shelter receiving the
contribution.
• Check – photocopy of the cancelled check, front and back - if not possible then a copy of the original check and a
receipt from the domestic violence shelter including the same information required of a cash donation.
• Credit Card – legible transaction receipt with the name and address of the domestic violence shelter; name,
address, and telephone number of the contributor; amount and the date the contribution was received; signature
of a representative of the domestic violence shelter receiving the contribution. Receipts should have the credit card
account number blacked out.
• Money order or cashiers check – legible copy of the original document with the name and address of the domestic
violence shelter, name, address and telephone number of the contributor; amount of the cash donation and the
date the contribution was received; signature of a representative of the domestic violence shelter receiving the
contribution.
MO 886-4281 (3-08)
