Qualified Investor Certification Application Form Certification For Calendar - 2016
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2Minnesota Department of Employment and Economic Development
Angel Tax Credit Program
Qualified Investor Certification Application Form
Certification for Calendar Year 2016
Data Privacy Notice:
per Minn. Stat. 116J.8737, Subd. 8, all data provided in this application is private data; certain
information becomes public upon certification as a qualified investor, upon a credit allocation, and upon a credit revocation.
Qualified investor’s names will be posted on the department’s website.
Tennessen Warning Notice:
per Minn. Stat. 13.04, Subd. 2, this data is being requested from you to determine if you may
be certified as a qualified investor eligible to apply for tax credits under the Angel Tax Credit Program. You are not required to
provide the requested information, but failure to do so may result in the department’s inability to certify you as a qualified
investor. Upon qualification and granting of tax credits under the Angel Tax Credit Program, this information will be shared
with the Minnesota Department of Revenue.
Section I. NAME AND IDENTIFYING INFORMATION (natural persons only)
Name: _______________________________________________ (SSN/TIN): ____________________
First
M.I.
Last
Taxpayer Id Number
Street Address 1: _____________________________________________________________________
Street Address 2: ______________________________ City: _________________________________
County (if in MN): _________________________ State: _____ Zip: ___________ Country_________
Email (required): ________________________________
Phone: ______________________________
COMPLETE ONLY SECTION II OR SECTION III, WHICHEVER IS APPLICABLE:
Section II. Investors who are accredited per SEC Rule 501-natural persons only (Check all that apply)
(a)
The undersigned is an individual with a net worth, or a joint net worth together with his or her
spouse, in excess of $1,000,000. (In calculating net worth, you may include equity in personal
property and real estate, cash, short-term investments, stock and securities. Equity in personal and
real estate should be based on fair market value of such property minus debt secured by such
property.
(b)
The undersigned is an individual who had gross income in excess of $200,000 in each of the prior
two years and reasonably expects an individual gross income in excess of $200,000 in the current
year.
(c)
The undersigned is an individual who had, with his or her spouse, gross income in excess of
$300,000 in each of the prior two years and reasonably expects an individual and spousal gross
income in excess of $300,000 in the current year.
OR
Section III. Investors who are not accredited investors -natural persons only (Check all that apply)
(a)
The undersigned is an individual who will only invest in a transaction that is exempt under
Minn. Stat. 80A.46 clauses (13) or (14).
80A.46 Exempt Transactions
(b)
The undersigned is an individual who will only invest in a security registered under Minn. Stat.
80A.50 (b).
80A.50 Small Corporate Offering Registration
Note: Investors may wish to consult legal or corporate counsel of the business to be invested regarding these attestations.
Section IV. ANGEL TAX CREDIT PROGRAM ACKNOWLEDGEMENT (Check to acknowledge)
MN DEED
Qualified Investor Certification
Angel Tax Credit Program
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Application Form 2016
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