Verification Of Contribution To A Missouri Certified Incubator Small Business Incubator Tax Credit Program Form Page 2
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2Revised December 2012 - Page 2 of 2
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I certify that I am an authorized representative of the applicant and as such am authorized to make the statement of affirmation
contained herein.
•
I certify that the applicant does NOT employ illegal aliens and that the applicant has complied with federal law (8 U.S.C. § 1324a)
requiring the examination of an appropriate document or documents to verify that an individual is not an unauthorized alien.
•
I understand that if the applicant is found to have employed an illegal alien in Missouri and did not, for that employee examines the
document(s) required by federal law, that the applicant shall be ineligible for any state-administered or subsidized tax credit, tax
abatement or loan for a period of five years following any such finding.
•
I attest that I have read and understand the Small Business Incubator Tax Credit Program guidelines, specifically as it relates to the
Tax Credit Accountability Act of 2004 (SB 1099).
•
I hereby agree to allow representatives of the Department of Economic Development access to the property and applicable records as
may be necessary for the administration of this program.
•
I certify under penalties of perjury that the above statements, information contained in the application and attachments are complete,
true, and correct to the best of my knowledge and belief
CONTRIBUTOR’S SIGNATURE
DATE
Must be signed in the
presence of a notary.
/
/
NOTARY EMBOSSER SEAL
STATE
COUNTY
MY COMMISSION EXPIRES
On this
day of
, 20
, before me,
, a Notary Public
in and for said state, personally appeared
, known to me to be
the person who executed the Certification and acknowledged and states on his/her oath to me
that he/she executed the same for the purposes therein stated.
NOTARY PUBLIC SIGNATURE
NOTARY RUBBER STAMP
NAME OF INCUBATOR
ADDRESS (STREET, PO BOX)
CITY
STATE
ZIP
TELEPHONE NUMBER
FACSIMILE NUMBER
(
)
–
(
)
–
I have examined this application and all attachments and believe it to be an accurate description of the contribution received by our
organization for the purposes of carrying out this application project.
INCUBATOR’S SIGNATURE
DATE
/
/
RETURN TO:
Department of Economic Development
Division of Business and Community Services
Finance Management
301 West High Street, Room 770
P.O. Box 118
Jefferson City, MO 65102
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