Recently, the IRS released a new form, Form Ph 3937, which applies to taxpayers who have made contributions to a qualified charitable organization. This form is used to report the amount of the contribution and to identify the qualified charity. Taxpayers are required to file this form if they want to claim a deduction for their donation. The purpose of this blog post is to provide an overview of Form Ph 3937 and explain how it should be completed. We will discuss who needs to file this form and what information needs to be included. Finally, we will provide some tips for completing this form accurately. Thank you for reading!
| Question | Answer |
|---|---|
| Form Name | Form Ph 3937 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | SSN, EMD, ems form, YYYY |
Office Use Only
File #
STATE OF TENNESSEE
DEPARTMENT OF HEALTH
DIVISION OF EMERGENCY MEDICAL SERVICES
HERITAGE PLACE, METRO CENTER 227 FRENCH LANDING, SUITE 303 NASHVILLE, TENNESSEE 37243 TELEPHONE:
EMS LICENSURE/CERTIFICATION
APPLICATION
LIC/CERT LEVEL REQUESTING:
SSN:
NAME:
FIRST RESPONDER
CLASS #:
EMT – IV
DOB:
PARAMEDIC EMD
MM |
DD |
YYYY |
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LAST |
FIRST |
MIDDLE |
(JR., II, III) |
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MAILING ADDRESS: |
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STREET ADDRESS |
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CITY |
COUNTY |
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STATE |
ZIP |
HOME TELEPHONE: ( |
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WORK TELEPHONE: ( |
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RACE:
WHITE
NATIVE
HISPANIC
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GENDER: |
HIGH SCHOOL DIPLOMA: |
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BLACK |
MALE |
YES |
NO |
ASIAN |
FEMALE |
GED: |
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OTHER |
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YES |
NO |
ARE YOU CURRENTLY OR HAVE YOU EVER BEEN LICENSED/CERTIFIED IN OTHER STATES OR WITH THE
NATIONAL REGISTRY? |
YES |
NO IF YES, LIST BELOW |
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STATE: |
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LEVEL: |
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LIC/CERT #: |
EXPIRATION DATE: |
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STATE: |
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LEVEL: |
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LIC/CERT #: |
EXPIRATION DATE: |
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HAVE YOU EVER BEEN CONVICTED FOR A VIOLATION OF THE LAW OTHER THAN A MINOR TRAFFIC |
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VIOLATION? |
YES |
NO |
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HAVE YOU EVER OR ARE YOU NOW ADDICTED TO ANY ALCOHOL OR DRUGS?
YES
NO
HAS YOUR LICENSE/CERTIFICATION TO PRACTICE IN ANY STATE EVER BEEN REPRIMANDED, SUSPENDED,
RESTRICTED, REVOKED OR IS IT UNDER THREAT OF DISCIPLINARY ACTION? |
YES |
NO |
If you answered yes to either question, give details on a separate sheet including circumstances with appropriate dates. Attach a certified copy of court records if convicted of any law violation.
I certify that all information in this form is correct and complete to the best of my knowledge. I understand that falsification of any information may be grounds for denial or revocation of my certification/license.
SIGNATURE:DATE:
"Under HIPPA, the health information you furnish on this document is protected from public inspection, absent a subpoena or for purposes of health oversight activities."
RDA 10140 |