Tennessee Rural Opportunity Fund - Certificate of Contribution for Tax Credit

Rural Opportunity Fund - Certificate of Contribution for Tax Credit
Rural Opportunity Fund and Small Business Opportunity Fund Certificate of Contribution for Tax Credit
TENNESSEE DEPARTMENT OF REVENUE

RV-F1319401 (5/18)

Rural Opportunity Fund and Small Business Opportunity Fund
Certificate of Contribution for Tax Credit

Part 1 - Business and Contribution Information (completed by contributor)
Name of Financial Institution
Business Mailing Address
Contact Person and Title

Telephone Number

Name of Parent Company (if applicable)
Tennessee Franchise and Excise Number
Tax Year (check one)

Calendar Year

Applicable Fund (check one)

Fiscal Year: from

Rural Opportunity Fund

to
Small Business Opportunity Fund

Qualified Contribution $
By

Date Approved

Signature

Print Name and Title

Date

Part 2 - Southeast Community Capital Certification (completed by SCC)
Amount of Eligible Contribution
Approved By

Signature

Print Name and Title

Date

Part 3 - Department of Revenue Certification (completed by Revenue)
Annual Amount of Credit
Approved By

Signature

Print Name and Title

Date

Tenn. Code Ann. § 67-4-2109(l) provides a credit for financial institutions that contribute to
the Tennessee rural opportunity fund or the Tennessee small business opportunity fund.
The credit is 10% of the contribution amount and can be taken each year for 10 years,
beginning with the year the contribution was made.
Financial institutions will qualify for this credit only upon contributing to one of the two
funds mentioned above, which are both administered by Southeast Community Capital
Corporation (d/b/a Pathway Lending). For more information about making a contribution,
please contact Pathway Lending at (615) 425-7171 or visit www.pathwaylending.org.

Part 1 – to be completed by financial institution contributing funds
• Enter the financial institution’s general business information.
• Indicate whether the contribution was to the rural opportunity fund or the small
business opportunity fund.
• Provide the amount of the qualified contribution and the date it was approved.
• This part should be signed by an officer of the financial institution.
• Submit the form to Pathway Lending for certification of contribution at: Pathway Lending,
201 Venture Circle, Nashville, TN 37228.
Part 2 – to be completed by SCC (Pathway Lending)
• Include the amount of the approved eligible contribution and sign and date.
• Submit the form to Department of Revenue for approval and calculation of tax credit at:
Tennessee Department of Revenue, P.O. Box 190644, Nashville, TN 37219-0644.
Part 3 – to be completed by Tennessee Department of Revenue
• Upon approval and calculation of the tax credit, the Department will send a letter to the
taxpayer confirming the taxpayer’s eligibility for the tax credit.