Fillable Form Fiia-01 - Eligibility Application (Page 3 of 4) in pdf

W V FO – Form FIIA-01: Eligibility Application

Page 3 of 4

Par t V - KE Y PERSONNEL CONTACTS

List only those officially attached to production.

Type of Contact

resident?

Name

Phone

Y / N

Main Contact/Title During Production

Secondary Contact/Title

Primary Tax Credit Contact/Title

Production Accountant

Executive Producer

Producer

Line Producer

Director

Production Manager

Unit Publicist

Lead Actor(s)

Par t VI - SIGNATURE AND VERIFICATION

Under penalties of perjury, I declare that I have examined this application, including any accompanying schedules

and statements, and to the best of my knowledge and belief, it is true, correct, and complete. I understand and

agree that this application is subject to committee review, will not be returned to applicant, and does not provide any

guarantee that it will be approved for the tax credit program.

I further understand and agree that: (1) if the application is approved, principal photography must commence

within 120 days of approval or applicant forfeits the right to claim any tax credit for the approved project and will be

removed from the queue, unless an extension has been approved a minimum of 30 days prior to expiration;

(2) pursuant to W.Va. Code §11-13X-6(a)(1), if the approved project contains screen credits, and upon request by

the film office, Applicant shall provide screen credit as follows: "Filmed in West Virginia with assistance of the WV

Film Industry Investment Act"; (3) issuance of tax credits will be subject to submission and review of an independent

Certified Public Accountant's expense verification report of the final accounting of WV expenditures, the cost of

which is applicant's responsibility; (4) before any tax credits are issued, a final shooting script reflecting any and

all revisions to the script that occurred during filming must be submitted to the West Virginia Film Office; and (5)

applicant will comply with all statutes and rules of the tax credit program stated in W. Va. Code 11-13X-1, et seq. and

110 CSR 13X, and confirms that the project (A) does not intend to and does not violate W. Va. Code §61-8C-1, et al.

[i.e., filming of sexually explicit conduct of minors]; (B) does not contain obscene matter or sexually explicit conduct,

as defined by W. Va. Code §61-8A-1; and (C) does not contain content that portrays the State of West Virginia in a

significantly derogatory manner (W. Va. Code §11-13X-3(b)(8)(F)).

I hereby confirm that I am a duly authorized representative of applicant and have the authority to submit this

application on its behalf.

Signature of Authorized Company Representative ______________________________________________ Date ___________________________________

PRINT Representative's Name and Title _______________________________________________________ Phone __________________________________

PRINT Name and Title of Preparer (if different from applicant)_______________________________________________________________________________

PRINT Preparer's Address and Contact Information (if different from applicant)

_________________________________________________________________________

Select state...

City _____________________________________

State ____________________________________

Department Use Only

Select country...

Zip _____________________________________

Country _________________________________

Date/Time Rec. _____________________________

Received By ________________________________

Phone __________________________________

Email ___________________________________

Application # _______________________________

West Virginia Film Office 90 MacCorkle Avenue, SW • South Charleston, WV 25303 • 866-698-3456 •

Form FIIA-01

9/14/12

Form Fiia-01 - Eligibility Application Page 3

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