Form N-317 - Statement By A Qualified High Technology Business (Qhtb)

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Form N-317
STATE OF HAWAII-DEPARTMENT OF TAXATION
Calendar Year
STATEMENT BY A QUALIFIED HIGH TECHNOLOGY BUSINESS (QHTB)
2002
(Developed 4/2003)
Name of Qualified High Technology Business
SSN or FEIN
GE ID No.
Please complete all applicable parts of Form N-317 on a calendar year basis and attach all required information. If a completed and signed Form N-
317 and the required attachments are not filed by June 16, 2003, the QHTB will be subject to sections 231-34, 231-35, and 231-36, Hawaii Revised
Statutes (HRS). See Department of Taxation Announcement No. 2003-1, RE: New and Revised High Technology Business Investment Tax Credit.
Please mail a completed and signed Form N-317 and attachments to the High Technology Filing Unit, Department of Taxation, P.O. Box 259,
Honolulu, HI 96809-0259.
Part I. QUALIFICATION AS A QHTB
A. Enter the date the QHTB began doing business in Hawaii:
__ __
/
__ __
/
__ __
B. Describe the nature of the QHTB’s business and briefly explain the product or service created or envisioned to be created by the
QHTB. Check here if a statement is attached: ______
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
C. Check the boxes that describe the qualified research activities performed by the QHTB in calendar year 2002.
The same as in section 41(d) of the Internal Revenue Code
The development and design of computer
Biotechnology, as defined in section 235-1, Hawaii Revised Statutes (HRS)
software, as defined in section 235-1, HRS,
Performing arts products, as defined in section 235-7.3(c), HRS
using fourth generation or higher software
Sensor and optic technologies
development tools or native programming
Ocean sciences
languages to design and construct unique and
Astronomy
specific code to create applications and design
databases for sale or license.
Nonfossil fuel energy-related technology
D. Please provide the following information based on actual activities of the QHTB during the calendar year 2002. Otherwise
provide the following information based on proposed activities of the QHTB for the calendar year 2003 and indicate that the
information is based on (a) QHTB's proposed activities for the calendar year 2003 and (b) the QHTB's best faith estimate: (1)(i)
list the number and describe the TOTAL jobs created by the QHTB, (ii) list the number and describe the NEW jobs created by the
QHTB, and (iii) list and describe whether such jobs are PERMANENT or TEMPORARY (temporary meaning a job in which a
new employee is hired for a specific duration of time or season); (2)(i) provide the total salaries and wages (by job classification)
paid by the QHTB, (ii) explain briefly whether any salaries, wages, or compensation for each job classification involves or
contemplates property (e.g., stock options), and (iii) provide a description of the quality and quantity of such property
compensation; (3) list, generally, the costs incurred in Hawaii, including employee costs (e.g., rental or purchase of property from
Hawaii sources, payments to Hawaii independent contractors for services); (4) briefly describe the QHTB's long-term business
plans in Hawaii and elsewhere and the benefits provided to Hawaii; and (5) describe any tax incentives, including the tax credit
for research activities as provided in section 235-110.91, HRS, claimed by the QHTB. If additional space is necessary, please
attach a statement. Check here if a statement is attached: ______
Part II. INVESTMENTS RECEIVED BY THE QHTB
A. Enter the total amount of investments received by the QHTB from investors in calendar year 2002: $_______________________
B. Attach a list containing the following information about each investor:
1.
Name, address, and SSN/FEIN of each investor of the QHTB;
2.
The amount of the investment and the date the investment was received;
3.
A description of the investment (e.g., cash, intangible personal property, tangible personal property, real property);
4.
If the investment is property, briefly explain and attach documentation supporting the valuation of the property; and
5.
What the investor received in return for this investment (e.g., the number of shares of stock in the QHTB, the number of units
in the QHTB, promissory note, license, etc.)
Declaration
I hereby certify under the penalties of perjury that I have the authority to sign Form N-317 on behalf of the QHTB. I declare, under the applicable penalties set forth in
sections 231-34, 231-35, and 231-36, HRS, and chapter 431, HRS, (if applicable) that the information reported on Form N-317 (including any accompanying lists,
schedules, statements, etc.) has been examined by me and, to the best of my knowledge and belief, is true, correct, and complete and made in good faith, pursuant to
Chapter 235, HRS (Hawaii Income Tax Law); and if applicable, pursuant to Chapter 241, HRS (Hawaii Taxation of Banks or Other Financial Corporations) and
Chapter 431, HRS (Hawaii Insurance Code).
Signature
Date
Print Name
Title
Form N-317
Developed 4/2003

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