Qualified Fund Annual Report Form Page 2
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1
2Date of
Name of business invested in
Original amount of investment
investment
B.
Angel tax credit investments no longer held by the fund as of December 31
List each qualified investment made by the fund for which angel tax credits were (or will be)
received by the fund’s member, but which are no longer held by the fund:
Note: Do not list dis-investments for which the three year holding period has passed.
Original
Date of
Date of dis-
Reason for dis-
Name of business invested in
amount of
investment
investment
investment*
investment
*Indicate reason using the following numeric choices:
(1) Investment became worthless, or
(2) 80% or more of the business’ assets were sold, or
(3) The business was sold, or
(4) Common stock of the business began trading on a public exchange, or
(5) Other (explain): ________________________________________________________________
Section III.
CERTIFICATION
The undersigned certifies that any statement or representation in this report, or information provided
herein, is true and complete to the best of his or her knowledge.
_______________________________________
__________________
_____________
Signature of authorized fund representative
Title
Date
Mail the Annual Report,
Annual Report Filing Fee: $100
A statutory late filing penalty of $500 applies to
with the Filing Fee (and late fee, if applicable), to:
Annual Reports postmarked after Feb 1st, for a
MN DEED
total amount of $600 to be submitted with a late
Angel Tax Credit Program, Attn: Jeff Nelson
filed Annual Report.
332 Minnesota Street, Suite E-200
St. Paul, MN 55101-1351
Make check payable to: MN DEED
MN DEED
Qualified Fund
Angel Tax Credit Program
2
2015 Annual Report Form
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