Form 3231 PDF Details

The purpose of Form 3231 is to provide the Internal Revenue Service (IRS) with information about a partnership’s basis in its partnership interests and its distributive share of each item of gross income, gain, loss, deduction, and credit of the partnership. The form is used to make the determination of whether a partner has an economic interest in a partnership. The form is also used to calculate how much gain or loss a partner has on the sale or exchange of their partnership interest. A Form 3231 must be filed for every taxable year that a domestic limited liability company (LLC) or foreign disregarded entity (FDE) is treated as a partnerships for federal tax purposes. A Form 3231 must also be filed by any taxable year that an LLC elects to be taxed as a corporation under section 801(a). This election makes the LLC subject to corporate rules and restrictions. However, an LLC continues to enjoy flow-through taxation on its net income at the partner level. For more information on

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Form NameForm 3231
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Rev. 07/2014

Georgia Department of Public Health

Form 3231

CERTIFICATE OF IMMUNIZATION

Child's Name (Last name first)

Birthdate

(Optional) Parent/Guardian Name (Last name first)

Date of Expiration

(Next required immunization or review of medical exemption due.)

(Fill in X)

Complete For K through 6th Grade

Child must be 4 years and have met all requirements for school attendance.

(Fill in X)

Complete For 7th Grade or higher

Fulfills requirements K through 6th grade AND must have Tdap and MCV4 documented

Unless specifically exempted by law, Georgia law (O.C.G.A. § 20-2-771) requires a certificate on file for each child in attendance in any school or child care facility in Georgia with penalties for failure to comply. Detailed instructions for this form and immunization requirements by age are spelled out in policy guides 3231INS and 3231REQ distributed by the Georgia Immunization Office.

VACCINE

DATE

DATE

DATE

DATE

DATE

MM DD YY MM DD YY MM DD YY MM DD YY MM DD YY MM

DATE

DD YY

Total Doses

Diagnosed

Serology +

History

Med. Exemption

Required Vaccines for School or Child Care Attendance

DTP,DTaP, DT,Td

Polio

Hepatitis B

Tdap

MCV4

HIB

(Under Age 5)

PCV

(Under Age 5)

Measles

Mumps

Rubella

Hepatitis A

(Born on/after 1/1/06)

Varicella

Recommended Vaccines (For Information Only)

Rotavirus

HPV (3 doses)

 

Influenza

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Td (booster)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Notes:

 

Printed, Typed or

 

 

 

 

A licensed Georgia physician, Advanced Practice Registered Nurse, Physician Assistant or

 

Stamped Name,

 

 

 

 

qualified employee of a local Board of Health or the State Immunization Office is responsible for the

 

 

 

 

 

content of this certificate. All dates must include month, day and year. In cases of natural immunity or

 

Address and

 

 

 

 

Medical Exemption, the 4 digit year of infection, test or exemption must be filled in the appropriate

 

 

 

 

 

box(es). The certificate is NOT valid without name and birthdate of the child, date of expiration

 

Telephone # of

 

 

 

 

OR "X" in Complete for School Attendance box, legible name and address of the physician,

 

 

 

 

 

 

 

 

 

 

Advanced Practice Registered Nurse, Physician Assistant or health department, certified by

 

Licensed

 

 

 

 

signature and a date of issue. A school or facility official is responsible for keeping a current valid

 

Physician

 

 

 

 

certificate on file for each child in attendance. A certificate must be replaced within 30 days after

 

 

 

 

 

 

or Health Dept.

 

 

 

 

expiration. When a child leaves or transfers to another facility, the Certificate of Immunization

 

 

 

 

 

should be given to a parent/guardian or sent to the new facility.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Certified by (Signature/Signature Stamp)

Date of Issue