DR 1317 (07/19/13) 
COLORADO DEPARTMENT OF REVENUE                                                      *131317==19999*
Denver, CO  80261-0005
www.TaxColorado.com

                                          Child Care Contribution  
                                          Tax Credit Certification
Organization Name

License Number or Colorado Account Number                    FEIN

Address                                                                                      Telephone Number
                                                                                             ( )
City                                                                                                   State Zip

Last Name of Preparer                                First Name                                               Middle Initial

Signature of Preparer

Donor Last Name                           First Name                          Middle Initial SSN or Colorado Account Number

Address                                              City                                              State Zip

                                                                                             Date of donation (MM/DD/YY)
Credit Computation

1. Donation amount                                                                              $

2. Non-qualifying donation                                                                      $

3. Qualifying donation, line 1 minus line 2                                                     $

4. Credit available, line 3 times 50%                                                           $
Application of Donation

        All functions of the donee organization qualify for the tax credit.

       The donation is applied 100% to qualified programs to the organization.

                                                     for all organization programs. 
       Qualified programs that constitute    %

       Other (describe allocation below)
Describe allocation

                                                     Instructions
This form is to be completed by the donee organization,      Social Security number may be completed by the donor 
then given to the donor. The donee organization should       after receipt from the donee organization.
retain completed copies for record keeping. 

Donors shall submit this form with their Colorado income    
tax return when claiming the child care contribution credit. 
When filing electronically, attach this form as a PDF to the 
electronic return, upload a copy in Revenue Online or mail 
with form DR 1778.