Schedule Fd - Food Donation Tax Credit Krs 141.392
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1
2SCHEDULE FD
Taxable Year Ending
*1600010340*
__ __ / __ __
41A720FD (06-16)
Mo.
Yr.
Commonwealth of Kentucky
F
D
T
C
OOD
ONATION
AX
REDIT
DEPARTMENT OF REVENUE
KRS 141.392
➤ Attach to Form 720, 720S, 725, 740, 740-NP , 741, 765 or 765-GP .
Name of Entity (Donor)
Identification Number (SSN or FEIN)
Kentucky Corporation/LLET Account Number
(if applicable)
__ __ __ __ __ __
__ __ __ __ __ __ __ __ __
Address (Number, Street, and Room or Suite No.)
City, State and Zip Code
Part I - Qualifications
• Are you a person responsible for and deriving income from:
1. Growing fruits, vegetables, or other edible agricultural products; or
2. Raising beef, poultry, pork, fish, or other edible agricultural products? .................................... ¨ YES ¨ NO
• Was the edible agricultural products that is intended for and fit for human
consumption raised or grown in Kentucky? ...................................................................................... ¨ YES ¨ NO
• Was the edible agricultural products provided free of fee or charge to a
nonprofit food program operating in Kentucky? ............................................................................... ¨ YES ¨ NO
If you answered “No” to any of these questions above, STOP, you do not qualify for this credit.
If you answered “Yes” to all questions above, go to Part II.
Part II - Information on Donated Food - To be completed by taxpayer making the donation and/or donee
Fruits
Vegetables
Beef
Poultry
Pork
Fish
Other edible product __________________________________
A
B
C
D
E
Description of
Date
Quantity of
Fair Market Price
Fair Market Value
Donated Food
Donated
Donation
Per Unit of Measure
(multiply Column C by Column D)
1.
1
00
2.
2
00
3.
3
00
4.
4
00
5.
5
00
6.
6
00
7. Total fair market value of donation (add Column E, lines 1 through 6) ..............................
7
00
8. Reimbursements received from all sources .........................................................................
8
00
9. Total fair market value of donation less reimbursements (subtract line 8 from line 7) ....
9
00
10. Credit percentage
10
10%
11. Credit amount. Multiply line 9 by line 10 ..............................................................................
11
00
12. Enter the unused prior year carryforward amount from the total line of the
Carryforward Worksheet ......................................................................................................... 12
00
13. Total credit amount (add lines 11 and 12). Enter result here and on applicable form or
schedule ................................................................................................................................... 13
00
Part III - Taxpayer (Donor) Statement
I, the undersigned, declare under the penalties of perjury, that to the best of my knowledge and belief, the information
and fair market values included in Part I are true, correct and complete.
Signature of Taxpayer (Donor) _________________________________________________________
Date __________________________________
_____________________________________________________________________________________
Type Name and Title of Person Signing This Document
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