This form is to authorize CICM.INC to submit your application for participation in the Qualified Education Expense Credit for the Georgia Department of Revenue. Please complete and submit this form.  All applications will be submitted to the GA Dept. of Revenue by CICM on Jan 1st of the next calendar year. Click here to download a printable version of this form. Please submit the printed version to CICM SSO by email, fax, or mail.

Taxpayer Name *
Taxpayer Name
No Dashes (-) Please
Spouse's Name
Spouse's Name
No Dashes (-) Please
New GA Filer
Is this the first calendar year for which you are filing income tax with the State of Georgia?
Are you a Business Owner?
Are you an Individual Owner or Part owner or spouse of an Owner of a S-Corp, LLC, partnership, or C-Corp?
Address *
Tax Credit Limit Individual - $1,000.00 Married Filling Separately - $1,250.00 Married Filling Jointly - $2,500.00 Individual Owner of S-Corp, LLCs, or Partnerships - $10,000.00 Taxpayer and Spouse Owner of S-Corp, LLCs, or Partnerships - $20,000.00 ($10,000.00 each) Note: This amount is not a commitment.
If left blank, your tax dollars will be applied to scholarship students at our partner school, Friendship Christian School.
Terms and Conditions *
Please use this form as my authorization to include me in the SSO program annually.
Type full name
Date *