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TAX CREDIT FOR LOW INCOME STUDENTS SCHOLARSHIP PROGRAM

sgo aNNUAL rEPORT

TAX CREDIT FOR LOW INCOME STUDENTS SCHOLARSHIP PROGRAM

SGO Annual Report June 1, 2022-May 31, 2023

Due no later than June 1, 2023

|Name of SGO | |

|Address of SGO | |

| | |

| | |

|Telephone of SGO | |

|Total Number of Contributions |Total Amount Contributions Received |Total Number of Scholarships Awarded |Total Amount of Scholarships Awarded |

|Received | | | |

| |$ | |$ |

_____________________________________________ ____________________

Chair of Scholarship Granting Organization Date

_____________________________________________ _____________________

Certified Public Accountant Date

of Scholarship Granting Organization

TAX CREDIT FOR LOW INCOME STUDENT SCHOLARSHIP PROGRAM

Annual Report June 1, 2022 - May 31, 2023

Monthly Contributions Report

|Month/Year |Amount of Contributions Received |Number of Contributions Received |

|JUNE 2022 |  |  |

|JULY 2022 |  |  |

|AUGUST 2022 |  |  |

|SEPTEMBER 2022 |  |  |

|OCTOBER 2022 |  |  |

|NOVEMBER 2022 |  |  |

|DECEMBER 2022 |  |  |

|JANUARY 2023 |  |  |

|FEBRUARY 2023 |  |  |

|MARCH 2023 |  |  |

|APRIL 2023 |  |  |

|MAY 2023 |  |  |

|TOTAL | | |

TAX CREDIT FOR LOW INCOME STUDENT SCHOLARSHIP PROGRAM

Annual Report June 1, 2022 - May 31, 2023

|Name of Student |Address |City |State |

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TAX CREDIT FOR LOW INCOME STUDENTS SCHOLARSHIP PROGRAM

Annual Report June 1, 2022 - May 31, 2023

SGO Notes-Optional

This page is for anything unique or a special circumstance for a student or your program you would like to note.

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inSTRUCTIONS:

The SGO Annual Report is due by June 1, 2023. Failure to submit this report to KSDE would place the SGO in non-compliance with the rules and regulations of the Tax Credit for Low Income Students Scholarship Program.

Complete the report for the period of June 1, 2022- May 31, 2023, using the most current data available.

Please sign and date the report before submitting. KSDE will be unable to accept any annual reports without the proper signatures and date.

Page 2: List the total contributions and the number of contributions received for each month during the reporting period on the Monthly Contributions Report.

Page 3 – Page 7: Make sure to total the student scholarship amount on each page

Page 8: List any eligible students that did not accept or were not offered a scholarship.

Page 9: List any notes or special circumstance related to student scholarships, contributions received or anything that the SGO would like to note about the program. Completion of this page is optional and not required.

The report can be submitted to the address below. Please do not submit the report via fax or via an unsecured email if the report contains any student data. The SGO can also submit this report via an encrypted email. The SGO can also submit this report encrypted by using KSDE.Secure.

Kansas state department of education

LANDON STATE OFFICE BUILDING

Attention: nicole Norwood

900 SW JACKSON sTREET, SUITE 354

TOPEKA, KANSAS 66612-1212

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