Form 569 - Reporting Form For The Transfer Or Allocation Of A Tax Credit
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5 State Of Oklahoma
569
AMENDED
Reporting Form for the Transfer or
REPORT!
Place an ‘X’ here if
this is an Amended
Allocation of a Tax Credit
Report:
Revised 2014
Part 1 – General Information
Tax Year:
FEIN or SSN:
Name of Person/Entity Transferring or Allocating a Credit:
Address:
City, State and ZIP:
Phone Number:
SELECT ONE:
Individual
Partnership
S-Corporation
Corporation
Fiduciary
Limited Liability Company
SELECT ONE:
1. You are filing this report as the person/entity who originally generated the credit.
-or-
2. You are filing this report as the person/entity to whom a credit was transferred or allocated and who is
transferring or allocating any portion of such credit to another person.
If you selected Number 2, enter the Name and FEIN/SSN of the person who transferred or allocated the
credit to you.
Name: ______________________________________________ FEIN/SSN: _____________________
Part 2 – Credit Information
1. Name of credit from Page 4 or Page 5: ________________________________________________________
2. Enter the line number of this credit (from Page 4 or Page 5): _______________________________________
3. Amount of credit: $ ________________________________________________________________________
Part 3 – Complete if any portion of the credit was transferred
Enter the Transferee Name
FEIN/SSN
Transfer Date
$ Amount of Credit Transferred
1)
2)
3)
4)
5)
6)
7)
8)
Total from Supplemental Schedule
9)
10) Total amount of credit that was transferred (add Part 3 lines 1 - 9)
(For allocated credits, complete Part 4 on page 2)
Under penalties of perjury, I declare I have examined this return, and to the best of my knowledge and belief it is true, correct and complete.
Signature
Date
Signature of Preparer
Date
Phone Number
Preparer Phone Number
The Oklahoma Tax Commission is not required to give actual notice to taxpayer of changes in any state tax law.
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