Transfer Of Tax Exemption Contract Form

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Deposit Date

Receipt #

LOUISIANA

Check #

Custom-Fit Opportunity

Check Amount

Initials

Amendment to Industrial

Tax Exemption Contract

TRANSFER OF TAX EXEMPTION CONTRACT

Contract No.

Parish Plant is located within

By my signature, I ___________________________________________________, ___________________________________________ of

Name

Title

__________________________________________________________________ certify, that our company has purchased and acquired title to assets of

New Owner

the manufacturing plant formerly known as ______________________________________________________________________________; located at

Former Owner/Name

_________________________________________________________ Parish of ______________________________________________

Louisiana Plant Location

Parish

That the said _____________________________________________________________________________ is covered by an Industrial tax

Former Owner/Name

exemption contract(s) with the State of Louisiana under Article VII, Part II, Section 21F of the Louisiana Constitution of 1974, and that the said

contract(s) was (were) acquired along with the said plant at the time of the acquisition of the other assets of the plant; That the said

_____________________________________________________________ will in the future continue to operate in the same manner and for the same

New Owner/Company Name

purpose as specified in the tax exemption contract prior to the act of transfer ; That this affidavit is made in compliance with Article VII of the contract for

the purpose of transferring the said contract from ________________________________________________________________________ to

_____________________________________________________________________________

A copy of the Secretary of State’ s form is also included. That this instrument will be considered by the undersigned as an amendment to the

above contract(s) embracing the said transfer when it has been executed by the State through an authorized representative of the Board of Commerce

and Industry and approved by the Governor.

Witnesses:

Company Name

Witness Printed/Typed Name

Signature

Witness Printed/Typed Name

Name/Title (Printed)

FEE: $250 must accompany form