Form Mo 419 2505 – Fill Out and Use This PDF

department of economic development

DRY FIRE HYDRANT TAX CREDIT CLAIM

PART 1 — TO BE COMPLETED BY THE TAXPAYER

1.individual name or name of firm or corporation to which the tax credit will be issued

2.address (street, and/or p.o. box), city, state, zip code

3.individual or business tax year

beginningending

4. social security number		business federal id number		missouri id number
5. taxpayer type (check one)
individual	corporation		s-corporation
partnership	other (specify: ________		__________________________________________________

(if s-corporation, partnership or other flow-through tax treatment entity, provide on a separate sheet the name, address and social security number or taxpayer id number for all persons or entities with an ownership interest. provide the percentage of ownership interest for each taxpayer as of the time of the application.)

6. type of expenditure

cash	in-kind
6a. cash: amount of cash expended
	enclose a copy of detailed invoice and proof of payment, including expenditures, cancelled checks, and/ $
	or credit card statement showing purchase and payment.
6b. in-kind: amount of in-kind contribution claimed
	enclose a detailed copy of how the in-kind contribution value was determined. note: no tax credits will be
$	issued for in-kind labor donations.

under the penalties of perjury, i certify that i am an authorized representative of the applicant and as such am authorized to make the state- ments of affirmation contained herein.

•i declare that i have examined this application, including all accompanying attachments, and to the best of my knowledge and belief they are true, correct and complete.

•i certify that the applicant does not employ illegal aliens and that the applicant has complied with federal law (8 u.s.c.§1324a) requiring the examination of an appropriate document or documents to verify that an individual is not an unauthorized alien.

•i understand if the applicant is found to have employed an illegal alien in missouri and did not, for that employee, examine the document(s) required by federal law, that the applicant shall be ineligible for any state-administered or subsidized tax credit, tax abatement or loan for a period of five years following any such finding.

title (printed or typed)

notary public name (typed or printed)

mo 419-2505 (10-07)

PART 2 — TO BE COMPLETED BY STATE FIRE MARSHAL OFFICE OR DESIGNEE

i certify that i have inspected the installed dry fire hydrant system and it meets the following requirements:

2the body of water or water storage unit provides two hundred fifty gallons per minute (250 gpm) for a continuous two-hour period during a fifty-year drought or freeze at a vertical lift of eighteen feet.

the dry fire hydrant is located within twenty-five feet of an all weather roadway and is accessible to fire protection equipment.

the dry fire hydrant is located within a reasonable distance from other dry or pressurized hydrants.

the dry fire hydrant substantially meets the national resources conservation missouri dry hydrant standard per rsmo. 320.093.

the site is not accessible for sole use by one individual and thus contributes to increased economic potential for the rural area.

signature		date
name, address and phone number of state fire marshal (or designee)

FOR OFFICIAL USE ONLY

date approved	reviewed by	log number
qualifying contribution	qualifying credit	authorization

this claim form and attachments shall be filed with the department of economic develop- ment for tax credit certification prior to claiming the benefits on your missouri tax return

mail to: the missouri department of economic development, dry fire hydrant tax credit program, p.o. box 118, jefferson city, mo 65102

mo 419-2505 (10-07)