Form Pc10 - Personal Computer Tax Credit Application - Indiana Department Of Revenue
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1Indiana Department of Revenue
PERSONAL COMPUTER
FORM
PC-10
TAX CREDIT APPLICATION
Do not write above
Rev. 7-97
Indiana Department of Revenue
Compliance Division
100 N. Senate Ave., Room N203
Indianapolis, Indiana 46204-2253
This form is to be accompanied by a Personal Computer Donation Form, completed by the Educational Service Center.
Name of Donor (Taxpayer)
Tax Year Ending
19
___________________________________
______________
____
Credit Verification Summary
Indicate below the number of units donated to each Educational Service Center (ESC)
Indicate type of income tax return to be filed by donor.
and date(s) of contribution. See instructions for list of service center drop-off locations.
Check one:
Location of
Number of units
Date(s) of
Individual: Forms IT-40, IT-40PNR
center:
at each center:
donation:
ESC 1........................ _______________
______________
Fiduciary: Form IT-41
ESC 2........................ _______________
______________
Insurance Tax Return
ESC 3........................ _______________
______________
ESC 4........................ _______________
______________
Financial Institution: Form FIT-20
ESC 5........................ _______________
______________
Not-for-Profit Organization: Form IT-20NP
ESC 6........................ _______________
______________
ESC 7........................ _______________
______________
Corporation: Forms IT-20, IT-20SC
ESC 8........................ _______________
______________
ESC 9........................ _______________
______________
An ESC Personal Computer Donation Form is
Total qualified Personal
attached for each unit donated.
Computer units donated:...........
X $100.
Multiply by:...............................
X
/
/
$
Total amount of credit
Signature of Educational Service Center Representative
Date
requested:...................................
Do Not Separate
Leave Form Intact
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Indiana Department of Revenue
Personal Computer Tax Credit
FORM
Tax Year
PC-20
Notice of Department’s Decision
Ending___________19____
Rev. 7-97
Attach approved PC-20 to the tax return on which the credit is claimed.
This section is to be completed by
Donor’s Social Security or Federal Identification Number
Telephone Number
The Indiana Department of Revenue
Your request has been:
Donor’s Name
Approved
Disapproved
Amount of credit allowed:
Mailing Address
Program Record
Number:
City
State
Zip Code
X
Signature of the Departmental Official
Date
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