SOUTH CAROLINA COMMISSION ON HIGHER EDUCATION              CHE-400
                                                                                                     (9/1/05)
                                         STUDENTS WITH DISABILITIES                                  0000
                                        TUITION TAX CREDIT VERIFICATION

Date: __________________           Tax Year in which you are filing: ______ (January 1 - December 31)

Part I. Taxpayer Information
Last Name: _________________________ First Name: ____________________ M.I.: ________
Social Security Number: _____-___-______
Mailing Address: _______________________________________________________________________
Phone Number: ( ) _____________

Part II. Student Information
Last Name: _________________________ First Name: ____________________ M.I.: ________
Social Security Number: _____-___-______
Mailing Address: _______________________________________________________________________
Phone Number: ( ) _____________
South Carolina Institution of attendance: _____________________________________________________

Part III. Disability Services Provider Verification
The Disability Services Provider at the institution of attendance must complete Part III. If the student attended more than
one institution in the tax year, a Verification Form must be completed for each institution of attendance and must be
verified by the Disability Services Provider at each institution of attendance.

Name: _____________________________                Title: ____________________________________________
Institution:______________________________________________
Office:__________________________________________________

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 (Spring, Summer, and Fall)
semesters. I have determined that this student was unable to successfully complete 30 credit hours (or credit hour
equivalents) this year. As a result, ______________________ was approved to enroll in less than 30 credit hours (or
credit hour equivalents) during the Spring, Summer, and Fall semesters.

__________________________________________         ____________________
Signature, Disability Services Provider            Date

Part IV.  Student / Taxpayer Verification
I hereby 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 hereby certify that the above Disability Services Provider has determined that the
credit hour requirement be reduced as a result of a documented and verified disability.

____________________________________________       ______________________
Student Signature (required)                       Date

____________________________________________       ______________________
Parent / Legal Guardian (required)                 Date

                This document must be attached to the South Carolina Department of Revenue
                Tuition Tax Credit Form (I-319) and submitted together with the SC1040.