State of Rhode Island Division of Taxation 
         Form CSO-1 
         Scholarship Organization Qualification Application

         TAX CREDITS FOR CONTRIBUTIONS TO SCHOLARSHIP ORGANIZATIONS

         SCHOLARSHIP ORGANIZATION QUALIFICATION APPLICATION 
             TO CERTIFY BY DECEMBER 31, 2021 ELIGIBILITY TO PARTICIPATE IN THIS PROGRAM IN 2022

               NAME

 Scholarship   ADDRESS

 Organization  CITY                                 STATE                              ZIP CODE
 Information
               FEDERAL IDENTIFICATION NUMBER                                     TAX YEAR END DATE

               NAME                                        TITLE

 Contact       PHONE NUMBER                                FAX NUMBER
 Information
               EMAIL ADDRESS

               NAME                                        PHONE NUMBER

               EMAIL ADDRESS
 Additional 
 Contact  
               NAME                                        PHONE NUMBER
 Information
               EMAIL ADDRESS

Under penalties of perjury, I declare that I have examined this entire application and to the best of my knowledge, all of the information is 
true, accurate, and complete.  I also certify that the scholarship organization: 
 
 (a) is a charitable organization in the State of Rhode Island that is exempt from federal taxation under section 501(c)(3) of the internal 
 revenue code; 
 (b) allocates at least ninety percent (90%) of its annual revenue through a scholarship program for tuition assistance grants to eligible 
 students to allow them to attend any qualified school of their parents’ choice represented by the scholarship organization; 
 (c) has a scholarship program that provides tuition assistance grants to eligible students to attend a nonpublic school located in this 
 state; and 
 (d) awards scholarships to eligible students without limiting availability to only students of one school.

                    Signature                                                    Title                     Date

               Please Print Name                    NOTE:SEE PAGE 2 FOR ADDITIONAL INFORMATION 
                                                           AND REQUIREMENTS 

Pursuant to RIGL 44-62-2 Qualification of scholarship organization - a scholarship organization must certify annually by December 31st to 
the Division of Taxation that the organization is eligible to participate in the program in the subsequent year in accordance with the above 
criteria.

         Mail completed application to RI Division of Taxation - One Capitol Hill - Providence, RI 02908 - Attn: Donna Dube

  State of Rhode Island Division of Taxation 
  Form CSO-1 
  Scholarship Organization Qualification Application

   TAX CREDITS FOR CONTRIBUTIONS TO SCHOLARSHIP ORGANIZATIONS

The following documents must be submitted with your application: 
 
  A copy of your organization’s 501(c)(3) exemption certificate 
  
  A copy of your organization’s most recently filed Form 990  
 
The following information must be provided for the organization’s 2021 tax year: 
   
  Total amount of revenue received by the SGO (from all sources):  $______________________ 
 
  Amount of revenue allocated to this program:                    $______________________ 
 
  The total amount of scholarships granted under this program:    $______________________ 
 
  List the schools represented by your organization:

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