Free INDIANA ENTERPRISE ZONE PROGRAM - Indiana

STATE FORM 50474 (R / 10-05)

INDIANA ENTERPRISE ZONE PROGRAM PETITION FOR BUSINESS REINSTATEMENT
PLEASE REFER TO IC 5-28-15-7(e) Please complete each section entirely, and remit the $100 civil penalty, payable to the Indiana Enterprise Zone Program: Indiana Economic Development Corporation Indiana Enterprise Zone Program One North Capitol, Suite 700 Indianapolis, IN 46204

,
(Name of person submitting petition) (Title)

of
(Name of Company)

being first duly sworn, upon his oath alleges and makes the following petition for the reinstatement of
(Name of Company)

in the enterprise zone program pursuant to IC 5-28-15:

GENERAL INFORMATION:
Name of Business: Business Type: ______ "C" Address: City, State: Phone: Zone Location Address: Zone City: Contact Person: Number of Years Participating in Program: Zip: Title: Zip: _______ "S" _______ "SP" _______ Other (specify)

STATE FORM 50474 (R / 10-05)

EMPLOYEE INFORMATION
Number of Employees: Number of Employees who are Zone Residents:

REINVESTMENT
Briefly describe how your business has reinvested the tax savings received either in your property, your employees, or in increased inventory.

SAVINGS INFORMATION
Disqualified Year Previous Year to Disqualified Year

Total Inventory Tax Savings: Total Gross Income Tax Exemption: Total Employment Expense Credit: Total Loan Interest Credit: Total Savings: Property Taxes:

STATE FORM 50474 (R / 10-05)

ZONE/COMMUNITY INVOLVEMENT
Please list and describe any Urban Enterprise Association programs or community programs in which the business participates.

REASONS FOR LATE FILING
Please list and describe the reasons for the business filing the EZB-R late or not at all.

STATE FORM 50474 (R / 10-05)

REASONS FOR REINSTATEMENT
Please list and describe the reasons for reinstating the business into the Indiana Enterprise Zone Program.

The foregoing constitutes the complete petition of . I certify, under the penalties of
(Name of Company)

perjury, that the representations in the forgoing petition are true and accurate.
(Signed Name)

(Printed Name)

(Title)

(Date)

STATE FORM 50474 (R / 10-05)

LOCAL SUPPORT
This section is to be completed by a representative from the local Urban Enterprise Association in which the petitioning business is located. Comment on the business' participation in the community, your discussion should include, but is not limited to the following: history of the business in the zone, more detail on the business' contributions to the enterprise zone, and specifics on the workforce of the business.

I,
(Name of UEA Representative)

have reviewed the petition for reinstatement on
(Name of Company) (Date)

for

.