Free 53651.FH11 - Indiana

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APPLICATION FOR MEDIA PRODUCTION EXPENDITURE TAX CREDIT
State Form 53651 (6-08)

FILM INDIANA INDIANA ECONOMIC DEVELOPMENT CORPORATION One North Capitol, Suite 700 Indianapolis, IN 46204 Telephone: (317) 234-2087 E-mail: [email protected]

INSTRUCTIONS: Please attach the following: 1. Detailed preliminary budget 2. Insurance certificate 3. Script and synopsis NOTE OF CONFIDENTIALITY OF INFORMATION

To the extent feasible and permissible by law, the Indiana Economic Development Corporation (IEDC) will honor an applicants request that confidential information submitted to the IEDC remains confidential. The IEDC will treat information as confidential only if: (i) the information is in fact protected confidential information such as trade secrets or privileged or confidential commercial or financial information, (ii) the information is specifically marked and identified as confidential by the applicant, (iii) the information is segregated and placed in a separate appendix to the application, and (iv) no disclosure of the information is required by law or judicial order. If the application results in a tax credit authorization, the honoring of the confidentiality of the identified data shall not limit the IEDCs right to disclose the details and results of the economic development project to the public.

The Media Production Expenditure Tax Credit may not be used in combination with the Qualified Media Production Gross Sales Tax Exemption, Lodging Tax Exemption, or any other Indiana Tax Credit. In order to be considered for the Qualified Media Production Expenditure Tax Credit, the taxpayer must spend a minimum of one hundred thousand dollars ($100,000) towards the production of a feature length film, short film, documentary, or television series, program or feature. A taxpayer seeking the credit for a digital media production that is intended for reasonable commercial exploitation, an audio recording or music video, an advertising message broadcast on radio or television, or a media production concerning training or external marketing or communications must spend at least fifty thousand dollars ($50,000) towards the production. Eligible expenses may include pre-production, production, and post-production expenses.
GENERAL INFORMATION
Name of Qualified Media Production Company Federal Identification number or Indiana Tax Identification number

Address (number and street, city, state, and ZIP code)

Doing Business As (D/B/A)

Business Structure (e.g. C-Corp, S-Corp, LLC, etc.)

Address (number and street, city, state, and ZIP code)

Contact person (person completing the application)

Title of contact person

Telephone number

Fax number

E-mail address

(

)

(

)
Title of senior company official

Senior company official

Telephone number

Fax number

E-mail address

(

)

(

)

Company website

Indiana office address (if different from applicant above) (number and street or PO Box, city, state, and ZIP code)

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NUMBER OF HIRES If necessary, please attach additional pages. Start and End Date for Position (month, day, year) Number of New Positions Position Average Starting Wage Without Fringe Average Starting Wage With Fringe Total Wages Paid

Description of the Qualified Media Production (check one of the following)

Feature Film Short Film Documentary

Television series, program or feature (does not include television coverage of news or athletic events) Digital Media Production Audio Recording
QUALIFIED MEDIA PRODUCTION TITLE

Music Video Advertising Message Training or Marketing

List the full names of the key personnel associated with this Qualified Media Production project to date.
Name of Director Name of Production Coordinator

Name of Executive Producer

Name of Location Manager

Name of Producer(s):

Name of Principal Actor(s):

1. 2. 3.

1. 2. 3.

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Has financing been completed for this production project?

Yes

No

Has financing been authorized by the entity financing this Qualified Media Production Project?

Yes

No

Expected operating date for the production office in Indiana (month/year) Date of the first occurence of principal photography in Indiana (month/year) Estimated number of days of principal photography in Indiana

FIRM OF INDEPENDENT CERTIFIED PUBLIC ACCOUNTANTS OR BOND COMPANY
Name

Address (number and street, city, state, and ZIPcode)

Telephone number

Fax number

E-mail address

(

)

(

)
PAYROLL SERVICE

Name

Address (number and street, city, state, and ZIPcode)

Telephone number

Fax number

E-mail address

(

)

(

)

EXPECTED EXPENSES FOR THIS QUALIFIED MEDIA PRODUCTION If necessary, please attach separate sheet(s). Project Item Wages, salaries, and benefits paid to Indiana residents Acquisition costs for a story or scenario used in the Qualified Media Production Acquisition costs for locations, sets, wardrobes, and accessories Expenditures for materials used to make sets, wardrobes, and accessories Expenditures for photography, sound synchronization, lighting, and related services Expenditures for editing and related services Facility and equipment rentals Food and lodging Legal services purchased from an attorney licensed to practice and located in Indiana Any other Qualified Media Production expenditure for which taxes are assessed by the state and is approved by the IEDC Total estimated Indiana qualified production expenditures Total estimated project budget CERTIFICATION The undersigned hereby certifies that he or she is authorized to execute and file this application with the Indiana Economic Development Corporation and that the representations contained herein are true and accurate. I certify that the Qualified Media Production does not depict obscene matter or an obscene performance as described in IC 35-49-2-1.
Signature of applicant Date signed (month, day, year)

Cost

Printed name of applicant

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