STATE OF SOUTH CAROLINASTATE OF SOUTH CAROLINA
      1350                                 DEPARTMENT OF REVENUEDEPARTMENT OF REVENUE
                                                                                                     CHE-400
                                         STUDENTS WITH DISABILITIES                                  (Rev. 7/21/20)
 dor.sc.gov                  TUITION TAX CREDIT VERIFICATION                                         9105
Tax year:
Part I: Taxpayer Information
Name:                                                                                    SSN:
Address:
City:                                      State:                  ZIP:                        Phone:

Part II: Student Information
Name:                                                                                    SSN:
Address:
City:                                      State:                  ZIP:                        Phone:
South Carolina institution of attendance:

Part III: Authorized disability services provider verification 
The disability services provider at the institution of attendance must complete this section.  
 
If the student attended more than one institution in the tax year: 
 • A verification form must be completed for each institution attended. 
 • The verification form must be verified by the disability services provider at each institution attended. 

Name:                                                              Title:
Institution:
Name of office or department:

I verify that ______________________ was certified under the Americans with Disabilities Act and Section 504 of the 
Rehabilitation Act of 1973 as a student with a disability prior to each semester of enrollment. I have determined  this 
student was unable to successfully complete 30 credit hours, or credit hour equivalents, this year. As a result, 
______________________ was approved to enroll in fewer than 30 credit hours, or credit hour equivalents, during the 
Spring, Summer, and Fall semesters.

            Disability services provider signature                                             Date

Part IV: Student and taxpayer verification 
I certify that the eligibility requirements for the Tuition Tax Credit are met in accordance with Section 2, Article 25, Chapter 
6, Title 12 of the 1976 Code. I certify that the above disability services provider has determined the credit hour 
requirement should be reduced as a result of a documented and verified disability.

              Student signature                                                                Date

            Parent or legal guardian signature                                                 Date

If you file by paper, attach this form to your I-319, Tuition Tax Credit, and submit to the SCDOR along with your SC1040, 
Individual Income Tax Return. If you file electronically, keep a copy with your tax records.

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