1. No category

Business Leadership Organized for Catholic Schools
Single Application for Educational Improvement Tax Credit (EITC)
and Opportunity Scholarship Tax Credit (OSTC)
1. Have you registered on the DCED website, www.newPA.com?
Yes
What is your user name? ________________ What is your password? _________________
No (BLOCS will assign a user name and password for your business)
2. Company Entity Type:
Limited Liability Partnership Sole Proprietorship S Corporation
Partnership Limited Liability Corporation C Corporation
3. Federal Employers Identification Number (FEIN) or SSN: _________________
4. NAICS* Code _________________
5. Company Entity Name: _______________________________________________________
6. Business Address: ___________________________________________________________
7. CEO: ______________________ CEO Title: ______________________
8. Application Contact Name: ____________________ Title: ___________________
Phone: ______________________ Email: ______________________
9. Are you applying for:
EITC
OSTC
Both
 Either
9a. EITC amount to be donated per year to BLOCS $ _________________
9b. OSTC amount to be donated per year to BLOCS $_________________
10. Enterprise type: _____________________________________________________________
11. Business Tax Year End: __________________ (mm/dd)
12. State: _______ County: ________________ Municipality: _________________
13. PA corporate Tax Account ID Number: _________________
(If your company does not have one write “0000-000”)
14. This application is for the following commitment
Year 1 of a 1 Year Commitment (75% Tax Credit)
Year 1 of a 2 Year Commitment (90% Tax Credit) Year 2 of a 2 Year Commitment (90% Tax Credit)
I hereby certify that all information contained herein is true and correct to the best of my knowledge. I acknowledge that tax credits will be awarded only for approved
contributions made to Scholarship Organizations listed by the Department (DCED) at www.newpa.com. I am aware that contributions must be made within 60 days of
the date on the approval letter and receipts must be forwarded to DCED by the business within 90 days of approval. Furthermore, I acknowledge that if I knowingly
make false statement to obtain tax credits, I (company, entity and signer) may be subject to criminal prosecution.
Signature: ___________________________________________ Date: __________________________
Print Name: __________________________________________ Title: __________________________
[APPLICATIONS CAN BE FAXED TO BLOCS AT 610-268-6275]
BLOCS
555 Croton Rd. Suite 310
King of Prussia, PA 19406
www.BLOCS.org