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Form QBA

Application for Designation as a Qualified Business for the

Qualified Equity and Subordinated Debt Investments Tax Credit

VA Dept. Of Taxation

See the instructions for details on when and where to file.

2601695 01/01

Name

Official Use Only

Business

Entity Type

Trading As

“ Corporation

Street address

Federal Employer Identification Number

“ S corporation

“ Partnership

City, State and ZIP Code

Virginia Account Number

“ Limited Liability

Company

Date Incorporated

Principal business activity code: IRS

VA Department of Taxation

Use this form to apply for designation as a qualified business for purposes of issuing equity or subordinated debt instruments which qualify for the Virginia

Qualified Equity and Subordinated Debt Investments Tax Credit. The credit provides individuals and estates and trusts a credit for making investments

in a qualifying business that is primarily engaged in business or does substantially all of its production in Virginia. IMPORTANT: This application must

be completed and timely filed by the issuing entity in accordance with the regulations (23 VAC 10-110-225 et seq.) prior to the issuance of any equity

or subordinated debt instruments; otherwise, such issuances will not qualify for the tax credit. If the Department of Taxation determines the entity is a

qualified business, such designation will only be valid during the calendar year of issuance. See instructions for investor information.

BUSINESS ENTITY IDENTIFICATION

(Attach a separate page if additional space is needed.)

See “ Qualified business” in instructions or Code of Virginia § 58.1-339.4.

“ No STOP; the business does not qualify

Is the business domiciled in Virginia? . . . . . . . . . . . . . . . . . . . . . . . . “ Yes

Is Virginia where the business entity is primarily engaged in business or

“ No STOP; the business does not qualify

does substantially all of its production? . . . . . . . . . . . . . . . . . . . . . . “ Yes

Were the business’ annual gross revenues

“ No STOP; the business does not qualify

for the most recent fiscal year less than $5,000,001? . . . . . . . . . . “ Yes

If yes, what were the gross anuual revenues? _________________________

Briefly describe the type of business or activities in which the entity is primarily engaged or primarily organized to engage.

__________________________________________________________________________________________________

ISSUANCE INFORMATION

Describe the type of instrument the business entity is planning to issue for purposes of this tax credit.

TYPE:

ANTICIPATED DATE OF ISSUANCE:

G Equity: ______________________________________________________________ Date: ____________________

G Subordinated debt:_____________________________________________________ Date: ____________________

Declaration: I, the undersigned officer or other person authorized to act on behalf of the business entity, have read and

understand the limitations and restrictions set forth for this application and the associated tax credit.

Authorized signature

Title

Date

Phone number

Printed Name _____________________________________________________________

: Write to Department of Taxation, P. O. Box 715, Richmond, VA 23218-0715 or call (804) 786-2992.

HERE TO

ELP

To order forms or regulations call 1-888-268-2829 (toll free outside Richmond), (804) 236-2760 or 236-2761. Our web page,

, contains most Virginia tax forms and additional tax information. Forms are available from your

Commissioner of the Revenue, Director of Finance, or Director of Tax Administration.

VA Dept. Of Taxation

Form Qba - Application For Designation As A Qualified Business For The Qualified Equity And Subordinated Debt Investments Tax Credit - Virginia Department Of Taxation

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