Qualified Seed Capital Business Investment Reporting Form - North Dakota Office Of State Tax Commissioner
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1North Dakota Offi ce of State Tax Commissioner
Qualifi ed seed capital business investment reporting form
► Applies to investments made on or after January 1, 2007
Instructions for
taxpayer’s annual gross income from
Amount of tax credit. To determine
qualifi ed business
the business, a government entity, or a
the amount of the tax credit allowed for
your investment, see the instructions to
tax-exempt organization.
Use this form only if you have been
your North Dakota income tax return
○ A spouse, parent, sibling, or child (or
certifi ed by the North Dakota Commerce
fi led for the tax year in which the date of
the spouse of a sibling or child) of an
Department’s Division of Economic
investment (as shown on this form) falls.
ineligible individual is also ineligible.
Development and Finance as a qualifi ed
business for purposes of the seed capital
•
Passthrough entity. If you are a
The investment is at risk. An investment
investment tax credit program under
partnership, S corporation, trust, or a
is at risk when it is available to the
N.D.C.C. ch. 57-38.5.
limited liability company treated like a
business for its use. Monies placed in
passthrough entity, the tax credit must
escrow are not at risk.
The information on this form applies
be calculated at the passthrough entity
to investments made on or after
A taxpayer who is a participant in a
level and passed through to the owners
January 1, 2007.
retirement plan with a separate account
or benefi ciaries based on their respective
maintained for the participant and who
You must complete and fi le this form for
interests in the entity. See the instructions
controls where the account’s assets
each qualifi ed investment received. Do
to Form 58 (partnership), Form 60 (S
are invested is deemed to have made a
not complete or fi le this form for an
corporation), or Form 38 (trust) for more
qualifi ed investment in the case of a direct
information.
investment that does not qualify for the
transfer of monies from the account to
tax credit. A qualifi ed investment is one
Angel fund. If you are an angel fund,
a qualifi ed business. When completing
that meets all of the following conditions:
the tax credit for your investment must
this form, enter the name, address, and
•
The investment is made in cash.
be passed through to your investors based
social security number of the individual
•
on their respective interests in the fund,
The investment is made on or after the
(participant), not the retirement plan.
regardless of whether the fund’s income is
date the qualifi ed business was certifi ed.
Filing instructions. Give a copy of the
•
subject to North Dakota income tax.
The investment is made by an eligible
completed form to the investor. Keep a
taxpayer.
copy for your fi les. File a copy of this
Contact Information
○ An eligible taxpayer means an
form with each of the following agencies:
If you have questions, contact us at:
individual, estate, trust, partnership,
•
Offi ce of State Tax Commissioner
•
regular (“C”) corporation, S
(701) 328-1247
600 E. Boulevard Ave. Dept. 127
corporation, or limited liability
(TDD/TTY call 1-800-366-6888 - ask
Bismarck, ND 58505-0599
company that is required to fi le a
for 701-328-1247)
•
Economic Development & Finance
North Dakota income tax return.
•
individualtax@nd.gov
PO Box 2057
○ An eligible taxpayer does not
•
Offi ce of State Tax Commissioner
Bismarck, ND 58502-2057
include a real estate investment
600 E. Boulevard Ave. Dept. 127
trust, a taxpayer having more than
Instructions for investor
Bismarck, ND 58505-0599
a 50 percent ownership interest
This form is evidence of your investment
in the business, a taxpayer who
in a qualifi ed seed capital business. Keep
receives more than 50 percent of the
it for your records.
Investment information
▼
Date of investment ►
Amount of investment ►
Investor’s tax type:
Individual
Partnership
Corporation
S corporation
Estate/trust
Limited liability company
Social security
Name of investor ______________________________________
number or FEIN _______________________
Spouse’s name,
Spouse’s social
if joint investment _____________________________________
security number _______________________
Address __________________________________ City __________________ State _______ ZIP _____________
Business certifi cation
▼
Name of qualifi ed business _________________________________________
FEIN ______________________
Signature of authorized representative ________________________________
Date ______________________
Printed name of authorized representative _____________________________
28276
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