Applicant Name__________________________________
Part F
Identification of Business type
Please check the box that describes the type of entity applying for the credit.
a partnership qualified to do business in the state,
a corporation qualified to do business in the state,
a limited liability company qualified to do business in the state,
a sole proprietorship, or
other, please explain___________________________________________________________________________
Part G
Applicant’s Signature
I, ______________________________________________________, swear under penalty of perjury that the foregoing
and all attachments are true.
X_____________________________________________________________________________ (Signature of applicant)
Subscribed and sworn before me this _______________________day of________________________, 20___________
Signature of notary_________________________________________________________________________________
My commission expires______________________________________________________________________________
Part H
Department of Revenue Expenditure Certification/Denial
Amount of certified expenditures ............................................................................ $ _________________________
(Must match the amount shown in Part A)
Date of delivery of above data and request for approval of taking credit ................ _________________________
Month and year
Signature and date for certifying expenditures
________________________________________________________________
_________________________
Name and title
Date
Signature and date for not certifying expenditures (See separate letter for reasons of denial and remedy)
________________________________________________________________
_________________________
Name and title
Date
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