Kentucky Application for Preliminary Authorization of the ENDOW Kentucky Tax Credit KRS 141.438

Application for Preliminary Authorization of the ENDOW Kentucky Tax Credit KRS 141.438
Form 41A720-S85
ENDOW

APPLICATION FOR PRELIMINARY
AUTHORIZATION OF THE ENDOW
KENTUCKY TAX CREDIT

APPLICATION
Commonwealth of Kentucky
Department of Revenue

2023

  See instructions.

A	 Name of Taxpayer	
	

B	 Federal Identification Number or	

	 	

	

C	 Kentucky Corporation/LLET

Social Security Number	

	

Street Address or P. O. Box			
City
	 	 	

State
	 	

D	 Type of Entity: 	

¨  Individual	

			

¨  General Partnership	

E	

¨  Estate	

¨  Trust	

Telephone
ZIP Code

¨  Corporation	

E-mail Contact

¨  Limited Liability Pass-through Entity

¨ Other

Submission Date of Application	
F	 Amount of Endowment Gift	
					

M M

 /     /
D D

Account Number (if applicable)

G	 Amount of Tax Credit

Y Y

H	 Name of Qualified Community Foundation	
	

or Affiliate Community Foundation

I	

Federal Identification Number	

Telephone

	

	 	

	

	

Fax Number

Street Address or P. O. Box			
City

State

ZIP Code

J	 If applicable, name of Permanent Endowment Fund or County-Specific Component Fund receiving the gift
	 Under penalties of perjury, I declare that I have examined the application, including all accompanying documents and
statements, and to the best of my knowledge and belief, it is true, correct, and complete.
	

By:  __________________________________________ 	

Date: _________________________________________

	

Print Name:  ___________________________________ 	

Title:  _________________________________________

	

	

Signature of Taxpayer or Authorized Representative

Consent to Release Preliminary Authorization of the Endow Kentucky Tax Credit
Notwithstanding the protections afforded taxpayers by Ky. Rev. Stat. (KRS) §131.190(1) and §131.081(15),
I, __________________________________________________ authorize the Kentucky Department of Revenue to release to
[print name of taxpayer]

__________________________________________________________________________________________________ ,
[name of qualified community foundation, county-specific component fund, or affiliate community foundation]

my name and the preliminary approval (including the amount) of an Endow Kentucky tax credit approved pursuant to
KRS §141.438 based upon the application for preliminary authorization of the tax credit for providing an
endowment gift to a qualified community foundation, county-specific component fund, or affiliate community
foundation.
_________________________________________________________________ 	 _________________________________
	

Signature of Taxpayer	

Date

Department of Revenue Use Only
Preliminary authorization of Endow Kentucky tax credit.
By:  	 _____________________________ 	 Date:  _________________________
41A720-S85 (3-23)	

Amount
Page 1 of 2

ENDOW (2023)

INSTRUCTIONS—APPLICATION FOR PRELIMINARY AUTHORIZATION
OF THE ENDOW KENTUCKY TAX CREDIT

Page 2 of 2

General Instructions
A taxpayer that seeks preliminary authorization of an Endow Kentucky Tax credit per KRS 141.438(7) for an endowment gift
to a permanent endowment held by an approved foundation (qualified community foundation, county–specific component
fund, or affiliate community foundation, which has been certified under KRS 147A.325) must file this Application with the
Kentucky Department of Revenue.
The process for acceptance and consideration of the application is set forth in 103 KAR 15:195 Sections 2 through 8. All
questions should be directed to:  [email protected].

Consent to Release Preliminary Authorization of the Endow Kentucky Tax Credit to Designee of Taxpayer
A taxpayer pursuing an Endow Kentucky tax credit by filing a written application may request notification of preliminary
approval for the tax credit to be provided to a qualified community foundation, county-specific component fund, or affiliate
community foundation. A request waiving confidentiality must (i) be made in writing; (ii) consent to disclosure of the taxpayer’s
name and the preliminary approval (including the amount) of the tax credit; and (iii) be signed by the taxpayer. The Consent
to Release section should be completed by filling in the taxpayer’s name, the name of the qualified community foundation,
county-specific component fund, or affiliate community foundation, and be signed by the taxpayer.

Submission Instructions
Choose one of the following options to submit the Endow application.
		 E-mail:	 [email protected]
		 Fax:	502-564-0058
	
Hand–delivery:	 Department of Revenue, 1st floor security desk at 501 High Street, Frankfort, Kentucky (call
502-564-8139 and ask for an employee in the Tax Credits Section.)

Note:	

This application contains time-sensitive information; therefore, mailing the application is not
recommended.

41A720-S85 (3-23)