Form 135 - Application For Initially Claiming Tax Benefits (Page 3 of 4) in pdf

MoDED 135

PAGE 3

13. Date taxpayer commenced the new or expanded operations at this facility. THIS DATE MUST BE FOR AT LEAST ONE

FULL MONTH DURING THE TAX PERIOD for which these tax benefits are being claimed, and must be during the FIRST

TAX PERIOD this NEW or EXPANDED PORTION OF THIS FACILITY was FIRST PUT INTO USE by the taxpayer claim-

ing these tax benefits (See instructions, page 16): (Month, Day and Year) ___________________________________

14. Did the taxpayer requesting tax benefits have interest(s) in any other BUSINESS(ES) in MISSOURI that FILE A SINGLE

MISSOURI TAX RETURN WITH THIS FACILITY for this tax period? ANSWER “YES” ONLY IF A SINGLE MO RETURN IS

FILED FOR THESE BUSINESSES (See instructions, page 16).

yes

14a. List names and FEIN numbers of other businesses FILING SINGLE MISSOURI RETURN WITH THIS FACILITY:

_________________________________________________________________________________________________

14a

15. Did the taxpayer of this new or expanded facility operate any other FACILITY(IES) in MISSOURI besides this new or

expanded facility during this tax period? ANSWER “YES” ONLY IF A SINGLE MISSOURI RETURN IS FILED FOR THESE

FACILITIES (See instructions, page 16).

yes

15a. List names and addresses of all Missouri facilities FILING SINGLE MISSOURI TAX RETURN WITH THIS FACILITY:

15a

_________________________________________________________________________________________________

THIS PORTION IS TO BE COMPLETED ONLY BY TAXPAYERS CLAIMING ENTERPRISE ZONE TAX BENEFITS. DO NOT

COMPLETE IF THIS FACILITY IS NOT WITHIN AN ENTERPRISE ZONE.

16. Excluding local, state or federal government funding sources, did the TAXPAYER incur costs to train employees AT THIS

ENTERPRISE ZONE FACILITY DURING THIS TAX PERIOD? IF YES, ATTACH SCHEDULE B. (See instructions, page

16: trainee must be zone resident or “difficult to employ.”)

yes

17. Were any of THIS FACILITY’S employees residents of a MISSOURI ENTERPRISE ZONE DURING THIS TAX PERIOD?

IF YES, ATTACH C SCHEDULE(S). (See instructions, page 16: addresses must be verified by enterprise zone

representative(s)).

yes

18. Were any of THIS FACILITY’S employees unemployed at least 90 days OR eligible for Temporary Assistance or the

General Relief Program AT THE TIME HIRED FOR THIS DEVELOPMENT? IF YES, ATTACH SCHEDULE D. (See instruc-

tions, page 17)

yes

19. Does the taxpayer elect to claim the new/expanded business facility tax benefits in lieu of the enterprise zone tax

benefits? (See instructions, page 17)

yes

THIS PORTION IS TO BE COMPLETED ONLY BY TAXPAYERS CLAIMING NEW OR EXPANDED BUSINESS FACILITY

TAX BENEFITS. DO NOT COMPLETE IF THIS FACILITY IS WITHIN AN ENTERPRISE ZONE.

20. At the time of commencement, or immediately prior to commencement of this expansion, addition, or replacement, did the

taxpayer operate ANY OTHER MISSOURI facility(ies), in addition to the new or expanded facility?

(See instructions, page 17)

yes

20a. If yes, describe the commercial operations at the OTHER FACILITY(IES). BE SPECIFIC. ______________________

_________________________________________________________________________________________________

20a

20b. Enter the Standard Industrial Classification (SIC) or NAICS number(s) of the OTHER FACILITY(IES) if known: _______

20b

21. Does the taxpayer elect to defer claiming this credit? (See instructions, page 17)

yes

21a. If yes, to what tax year is credit deferred -- may be deferred up to three additional tax periods (See instructions, page

17): Tax Period Ending (Month, Day and Year) ____________________________________________________________

21a

CERTIFICATION (See instructions, page 17-18):

•

I certify that I am an authorized representative of the applicant and as such am authorized to make the statement of affirmation

contained herein.

•

I certify that the application does NOT employ illegal aliens and that the applicant has complied with federal law (8 U.S.C. §

1324a) requiring the examination of an appropriate document or documents to verify that an individual is not an unauthorized

alien.

•

I understand that if the applicant is found to have employed an illegal alien in Missouri and did not, for that employee examine

the document(s) required by federal law, that the applicant shall be ineligible for any state-administered or subsidized tax cred-

it, tax abatement or loan for a period of five years following any such finding.

•

I attest that I have read and understand the New and Expanded Business Facility or Enterprise Zone Tax Credit Program guide-

lines, specifically as it relates to the Tax Credit Accountability Act of 2004 (SB 1099).

MO 419-1524 (11-04)

Form 135 - Application For Initially Claiming Tax Benefits Page 3

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