PIAKP Contribution Receipt

REVENUE DIVISION

Tax Credits/Special Refunds

1816 W 7th St., Room 2370

Post Office Box 8054

Little Rock, Arkansas 72203-8054

Phone: (501) 682-7106

Fax: (501)682-4896

www.dfa.arkansas.gov
Philanthropic Investment in Arkansas Kids Program

Tax Credit Application and Receipt of Eligible Contribution
1. Scholarship Granting Organization
Name of Organization: ACE Scholarships SGO Arkansas, LLC

FEIN: 87-4130018

Address: 5251 DTC Pkwy, Ste 300, Greenwood Village, CO 80111

Telephone: (303) 407-0611

Name and Title of SGO Official Completing Form: Tina Burke, Director of Development Operations
2. Donor
Type of Entity:*

IndividualLLC*Partnership *Corporation
* If entity is Partnership or LLC, please provide a separate attachment that includes name of members, SSN/FEIN, and ownership percentage.
Legal Name*
FEIN/SSN*
Address/City/State/Zip*
Telephone*
3. Eligible Contribution Information
Eligible Contribution Amt*
Eligible Contribution Date*

MonthDayYear
Date
Method of Contribution *
Cash, Check, Credit Card, EFT
Consent to Release Tax Credit Information to SGO - Donor authorizes the Department of Finance and Administration (DFA) to notify the Scholarship Granting Organization (SGO) of the amount of tax credit that is certified and granted to Donor (Donor's initial required in appropriate box below)
YES, I consent

Clear
Donor Initials
NO, I do NOT consent

Clear
Donor Initials
4. Signatures of SGO Official and Donor
The persons signing below affirm that the information contained within this application is true and accurate and the eligible contribution above was made by the Donor and actually received by the SGO. In order for this application to be considered for a tax credit, the SGO must provide a copy of this completed and signed application to the Tax Credits/Special Refunds Section of the Department of Finance and Administration electronically at the following e-mail address: PIAKP.TaxCredit@dfa.arkansas.gov.
Date*

MonthDayYear
Date
Signature of Donor*

Clear
Should be Empty:

Philanthropic Investment in Arkansas Kids Program

1. Scholarship Granting Organization

2. Donor

3. Eligible Contribution Information

4. Signatures of SGO Official and Donor