Schedule Fd (Form 41a720fd) - Food Donation Tax Credit
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1
2SCHEDULE FD
Taxable Year Ending
*1400030340*
__ __ / __ __
41A720FD (06-14)
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 - 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. Enter result here and on applicable form
or schedule ..............................................................................................................................
11
00
Part II - 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
Part III - Donee Acknowledgement - To be completed by the charitable organization
I, the undersigned, declare under the penalties of perjury, that this charitable organization is exempt from federal
income tax under Section 501(c)(3) of the Internal Revenue Code, that it operates a surplus food collection and
distribution program as defined in KRS 141.392(1)(c), and that I have examined this schedule, and to the best of my
knowledge and belief, it is true, correct and complete.
Name of Charitable Organization (Donee)
Employer Identification Number
Address (Number, Street, and Room or Suite No.)
City, State and Zip Code
Authorized Signature
Title
Date
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