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Georgia Form IT-QRHOE-TP2 (Rev. 05/09/17)Qualified Rural Hospital Organization Expense Tax Credit Computation

Please print your numbers like this in black or blue ink:

Georgia Department of Revenue

Please print your numbers like this in black or blue ink:

FIRST NAME OR NAME OF ENTITY MI TAXPAYER IDENTIFICATION NUMBER

DEPARTMENT USE ONLY

CORPORATION INDIVIDUAL FILING MARRIEDJOINT RETURN

If I deducted this amount from my Federal income, I added it back to my Georgia income tax.(If it was not, the credit cannot be claimed)

I did not designate this amount for a particular individual.(If you did, the credit cannot be claimed)

INDIVIDUAL FILING MARRIED SEPARATE RETURN

INDIVIDUAL FILING SINGLE OR HEAD OF HOUSEHOLD

This form is the last step in the process of the qualified rural hospital organization expense tax credit. This form is completed by the taxpayer and attached to their income tax return when it is filed. This form is used to compute the qualified rural hospital organization expense tax credit.

Fill in either A or BA. Individuals

. 00

.,,,

00

., 00 3. Fill in the pre-approved amount here from the Form IT-QRHOE-TP1 that was returned to

you by the Department..................................................................................................

4. Tentative credit allowed before income tax liability limitation. The lesser of line 2 or 3......

1. Total amount expended.................................................................................................

Page 1

LAST NAME IF INDIVIDUAL SUFFIX

FIDUCIARY

. 00 2. Line 1 X .90.....................................................................................................................

Georgia Department of Revenue

75%

1. Total amount expended ........................................................................

2. Line 1 X .90..........................................................................................

4. Tax liability...........................................................................................

5. Percentage Limitation...........................................................................

6. Multiply line 4 by line 5.........................................................................

Credit allowed. Lesser of lines 2, 3, or 6................................................

B. Corporations and Fiduciary

, .,

00.. 00

00.

. 00

007.

,

,,

,

,

,,

, 3. Total amount preapproved..................................................................... 00.,,

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Requirements

O.C.G.A § 48-7-29.20 establishes the qualified rural hospital organization expense tax credit. The credit is allowed for thecontribution of funds by the taxpayer to a rural hospital organization, which meets the requirements under O.C.G.A § 31-8-9.1.

In order to claim this tax credit, the amount must have been preapproved by the Department of Revenue. Once pre-approval was received, the taxpayer must have made the contribution to the rural hospital organization within 60 days ofthe date of the preapproval notice received from the Department and within the calendar year in which it was preappoved.

Within 30 days of making the contribution, the taxpayer must report through the Georgia Tax Center the amount of the con-tribution and the Department issued tax credit certificate number and must provide a copy of Form IT-QRHOE-RHO1. Fail-ure to do so will result in the permanent loss of the credit.

Individual Taxpayers.

Enter the credit allowed on the appropriate income tax form and attach this form.

(1) For an individual taxpayer, the credit amount shall not exceed 90% of the actual amount expended or $5,000, whichever is less.(2) For an individual taxpayer filing a married filing separate return, the credit amount shall not exceed 90% of the actualamount expended or $5,000, whichever is less.(3) For an individual taxpayer filing married filing joint, the credit amount shall not exceed 90 percent of the actual amount expended or $10,000, whichever is less.

For an individual taxpayer the tax credit is further limited and may not exceed the taxpayer’s income tax liability. The amountof the tax credit (90% of the actual amount expended or the credit limits described above, whichever is less) that exceedsthe taxpayer’s income tax liability can be used against the next succeeding five years’ tax liability.

Georgia Form IT-QRHOE-TP2 (Rev. 05/09/17)Qualified Rural Hospital Organization Expense Tax Credit Computation

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Corporate and Fiduciary Taxpayers

For a corporation or fiduciary taxpayer, the credit amount shall not exceed, 90 percent of the actual amount expended, theamount preapproved, or 75 percent of the corporation’s or fiduciary’s income tax liability, whichever is less. Any lesser amount (90% of the amount expended, the amount preapproved, or 75% of the corporation’s or fiduciary’s income tax liability, whichever is less) that is not used can be used against the succeeding five year’s income tax liability. A fiduciarycannot pass-through the credit to its beneficiaries.

Georgia Form IT-QRHOE-TP2 (Rev. 05/09/17)Qualified Rural Hospital Organization Expense Tax Credit Computation

Georgia Department of Revenue

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