Florida Tax Credit Scholarship Program                                       DR-116100
                                                                                                                    R. 01/19
 Application for Rescindment of Previous Allocation of Tax Credit                                         Rule 12-29.003, F.A.C.
                                                                                                                    Effective 01/19
 (Under sections [ss.] 211.0251, 212.1831, 220.1875, 561.1211, 624.51055,                                           Page 1 of 2
                                           and 1002.395, Florida Statutes, [F.S.])

Business name ___________________________________________________________________________________________

Federal Employer Identification Number (FEIN)            –                             

Mailing address __________________________________________________________________________________________

City ___________________________________________  State _____________  ZIP __________________________________

Contact person ___________________________  Contact’s telephone number  ____________________________________

Contact person's email address ____________________________________________________________________________

If included in a consolidated Florida corporate income tax return, provide:

Parent Corporation’s FEIN    –                               

Original amount of planned contribution  $            ,              ,                 .   

Confirmation number of original credit allocation application __________________________________________________

Enter the name of the SFO the credit was originally approved for:

_________________________________________________________________________________________________________

Enter the amount you wish to rescind  $            ,              ,                 .     
Enter the amount(s) below to rescind based on the tax type. (The sum of the amounts by tax cannot exceed the total 
amount you wish to rescind above. The amount to be rescinded for each tax cannot exceed the amount allocated to 
that tax on the original application.):
 ______________ Corporate Income Tax (Chapter 220, F.S.)
 ______________ Insurance Premium Tax (s. 624.509, F.S.)
 ______________ Excise Tax on Malt Beverages (s. 563.05, F.S.)
 ______________ Excise Tax on Wine Beverages (s. 564.06, F.S.)
 ______________ Excise Tax on Liquor Beverages (s. 565.12, F.S.)
 ______________ Sales Tax Paid by a Direct Pay Permit Holder (s. 212.183, F.S.)
 ______________ Tax on Oil Production (s. 211.02, F.S.)
 ______________ Tax on Gas Production (s. 211.025, F.S.)

I understand that section (s.) 1002.395(5)(f), Florida Statutes (F.S.), requires the Florida Department of Revenue to 
provide a copy of any approval or denial it issues with respect to this application for rescindment to the nonprofit 
scholarship-funding organization indicated on the associated application for an allocation of credit.

Under penalty of perjury, I declare that I have read this application form and that the facts stated in it are true.

________________________________________________                               ______________________
 Signature of officer, owner, or partner                                                              Date

                                                                                                           DR-116100
                                                                                                                   R. 01/19
                                                                                                           Page 2 of 2

                             Instructions for Completing Form DR-116100

You may apply to the Department for rescindment of all or    The Department will send written correspondence 
part of a previously approved allocation of tax credit under regarding the approved rescindment amount or the reason 
the Florida Tax Credit Scholarship Program using the         the rescindment request could not be approved.
Department's website at
                                                             The Department will approve the rescindment unless:
floridarevenue.com/taxes/sfo. You must submit 
a separate application for the rescindment of each           (1)  You have claimed the credit amount to be rescinded 
previously approved credit allocation.                       on a previously filed tax return.
Once you have entered the requested information, a           (2)  The allocation year is closed for all taxpayers. 
confirmation screen with a confirmation number will          The allocation for a particular year is closed for 
appear. This screen will display the information entered     all taxpayers on October 1st of the third year 
and confirm receipt of the electronic application for        after the January 1 opening of the allocation 
rescindment. You can print this screen or simply record      period. For example, the allocation year beginning 
the confirmation number to prove that you submitted an       January 1, 2018, for the state fiscal year 
application for rescindment.                                 beginning July 1, 2018, closes for all taxpayers on 
                                                             October 1, 2020, regardless of whether the annual 
If you don't have your original confirmation number 
                                                             allotment has been reached because October 1, 2020, 
contact the Revenue Accounting section at 850-617-8586.
                                                             is the extended due date of the last tax year beginning 
                                                             in the 2018 calendar year (tax year beginning 
                                                             December 1, 2018, and ending November 30, 2019, 
                                                             with a due date of April 1, 2020, and extended due 
                                                             date of October 1, 2020).