Free 52341.FH11 - Indiana

QUALIFIED INDIANA BUSINESS APPLICATION
State Form 52341 (R2 / 12-08) Approved by State Board of Accounts, 2008 INDIANA ECONIMIC DEVELOPMENT CORPORATION (IEDC) VENTURE CAPITAL INVESTMENT (VCI) TAX CREDIT PROGRAM

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INDIANA ECONOMIC DEVELOPMENT CORPORATION VCI TAX CREDIT PROGRAM One North Capitol Avenue, Suite 700 Indianapolis, Indiana 46204

INSTRUCTIONS:

1. To have your application processed, mail this signed original application to the above address. 2. Please enclose the entire application and the non-refundable $200.00 application fee, payable to the Indiana Economic Development Corporation. 3. Please provide a full business plan, including pro forma financial statements and the most current interim financial statements. Also try to include the following: product / service description; management overview; product / service development strategy; target market and marketing plan; operational summary; critical market risks; financing plan;milestones and exit strategies. Also include a separate and complete executive summary of the business plan that summarizes the entire business plan in 3-4 pages. Failure to provide a complete business plan and executive summary may delay the processing of the application. 4. Processing these applications may take up to 4-6 weeks 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].

The IEDC's certification of a company as a Qualified Indiana Business is based upon representations contained herein. The information contained in this application is subject to verification by the IEDC. If the IEDC is unable to verify any information contained herein or determines any of the information to be inaccurate or misrepresented, a company's designation as a Qualified Indiana Business may be revoked at IEDC's sole discretion. To the extent feasible and permissible by law, the IEDC will honor an applicant's request that confidential information submitted to the IEDC remains confidential. The IEDC will treat the 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. APPLICANT INFORMATION
Name of company NAICS code Structure (check one) Federal identification / tax number Indiana identification / tax number

S Corp
Address (number and street, city, state, and ZIP code) Main telephone number

C Corp

LLC

LLP

LP

Other (specify) ___________________________
County

(

)

Main facsimile number

(

)

Web address Title

Name of contact person Telephone number Facsimile number

(

)

(

)

E-mail address

Is the address above the companys headquarters?

Yes
Address (number and street, city, state, and ZIP code) Main telephone number Main facsimile number

No

If no, please complete the following information.
County E-mail address

(

)

(

)

List the current owners / shareholders / members of the above business. If necessary, please use the same format on an additional sheet and attach to this application.
Name Percentage of ownership Federal identification / tax number Affiliation / relationship to other owners / shareholders / members County Web / e-mail address Federal identification / tax number Affiliation / relationship to other owners / shareholders / members County Web / e-mail address Indiana identification / tax number Indiana identification / tax number

Address (number and street, city, state, and ZIP code) Main telephone number Main facsimile number

(

)

(

)

Name Percentage of ownership

Address (number and street, city, state, and ZIP code) Main telephone number Main facsimile number

(

)

(

)

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OTHER COMPANY RELATED INFORMATION
The qualified Indiana Business Applicant is engaged in the following (check all that apply):

Real estate Accounting Insurance

Real estate development Technology transfer Oil or gas exploration

Application of new technology Professional motor vehicle racing Professional services as a lawyer or physician

Commercialization of research and development Retail sales (Do not check if the business is the development
or support of electronic commerce using the Internet.)

Amount of revenue generated last year Amount of capital from outside Indiana

Amount of revenue generated the year before last Total value of company assets

Amount of capital company plans to raise in this round Value of those assets in Indiana

Now Total company employment Total employment of Indiana residents

EMPLOYMENT INFORMATION End Year One

End Year Two

Thereafter

AFFIRMATION I affirm, under the penalties for 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 (IC 6-3.1-24).
Signature Printed name Title Date (month, day, year)

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