Free 52340.FH11 - Indiana

QUALIFIED CAPITAL INVESTMENT APPLICATION
State Form 52340 (R2 / 2-07)

INDIANA ECONOMIC DEVELOPMENT CORPORATION (IEDC) VENTURE CAPITAL INVESTMENT (VCI) TAX CREDIT PROGRAM Please refer to the instructions provided on page 2. INFORMATION ABOUT QUALIFIED INDIANA BUSINESS (QIB)
Name of QIB that will receive the proposed Qualifiied Investment Capital

Address of QIB that will receive the proposed Qualified Investment Capital (number and street, city, state, and ZIP code)

County

Telephone number (main)

Facsimile number (main)

Web address

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)

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) Please attach a copy of the companys certification
INFORMATION ABOUT INVESTOR

Date of certification as a QIB by the Indiana Economic Development Corporation (month, day, year)

Name of investor (company/individual)

Affiliation/relationship to other owners/shareholders/members

Federal Identification/Tax number

Indiana Identification/Tax number

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

County

Telephone number (main)

Facsimile number (main)

Web address

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)

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)
Title

Name of contact person

Telephone number of contact person

Facsimile number of contact person

E-mail address of contact person

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)

(

) Yes No

Are you employed by the Qualified Indiana Business?

INFORMATION ABOUT INVESTMENT

A. For this application only, what is the amount of your proposed investment in this company? $ B. In what form will your proposed investment be? (Please check all that apply) Debt Equity

Please note that debt investments from financial institutions that are secured by a valid mortgage, security agreement or other agreement or document that establishes a collateral or security position for the financial institution that is senior to all collateral or security interests of other taxpayers that provide debt or equity capital to the Qualified Indiana Business do not qualify for VCI Tax Credits. C. In an attachment, provide fully diluted ownership positions before and after your proposed investment. (NOTE: Generally, investors who hold a majority ownership position, or who as a result of making their proposed investment, will hold a majority ownership position, are not eligible for the VCI Tax Credit.) D. Provide the anticipated date on which the proposed qualified investment will be made: (NOTE: No investments made prior to Indiana Economic Development Corporation (IEDC) approval will be eligible for the Venture Capital Investment (VCI) Tax Credit Program. Qualified investments must occur within two (2) years after the date that the IEDC certifies the investment plan for the Indiana VCI Tax Credit program.)

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AFFIRMATION

I hereby affirm, under the penalties of perjury, that the information contained herein is true and accurate to the best of my knowledge and belief. I furthermore affirm that I have read and understand the statute governing this program (Indiana Code 6-3.1-24).
Signature of applicant Date (month, day, year)

Printed name of applicant

Title

INSTRUCTIONS

1. To have your application processed, please mail this original signed application to: Indiana Economic Development Corporation VCI Tax Credit Program One North Capitol Avenue, Suite 700 Indianapolis, Indiana 46204 2. Please enclose the entire application (including attachments). To do otherwise could cause a delay in the processing of the application. Processing this application may take up to 5-7 business days from the date of receipt of a complete application. If the allotted time elapses without a decision letter from us, please contact Lee Robinson, Financial Analyst, at 317-233-3638 or [email protected]. 3. After making your investment, please provide a letter from a Qualified Indiana Business authorized representative verifying the investment was made, a copy of an executed stock purchase agreement or other evidence of the investment, and a copy of the canceled check(s) or evidence of the wire transfer(s). IEDCs certification of a tax credit based on this application relies upon representations contained herein and upon representations made by the Qualified Indiana Business. The information contained in this application and in the application by the Qualified Indiana Business is subject to verification by the IEDC. If the IEDC is unable to verify any information contained in this application or in the application by the Qualified Indiana Business or determines any of the information to be inaccurate or misrepresented, a companys designation as a Qualified Indiana Business may be revoked and credits issued may be nullified at the IEDCs sole discretion.

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