Form 52340 - Qualified Capital Investment Application Page 2
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2AFFIRMATION
I hereby affirm, under the penalties of perjury, that the information contained herein is true and accurate to the best of my knowledge
and belief. I furthermore affirm that I have read and understand the statute governing this program (Indiana Code 6-3.1-24).
Signature of applicant
Date (month, day, year)
Title
Printed name of applicant
INSTRUCTIONS
1. To have your application processed, please mail this original signed application to:
Indiana Economic Development Corporation
VCI Tax Credit Program
One North Capitol Avenue, Suite 700
Indianapolis, Indiana 46204
2. Please enclose the entire application (including attachments). To do otherwise could cause a delay in the processing of the application.
Processing this application may take up to 5-7 business days from the date of receipt of a complete application. If the allotted time
elapses without a decision letter from us, please contact Lee Robinson, Financial Analyst, at 317-233-3638 or lrobinson@iedc.IN.gov.
3. After making your investment, please provide a letter from a Qualified Indiana Business authorized representative verifying
the investment was made, a copy of an executed stock purchase agreement or other evidence of the investment, and a copy
of the canceled check(s) or evidence of the wire transfer(s).
IEDC’s certification of a tax credit based on this application relies upon representations contained herein and upon representations
made by the Qualified Indiana Business. The information contained in this application and in the application by the Qualified Indiana
Business is subject to verification by the IEDC. If the IEDC is unable to verify any information contained in this application or in the
application by the Qualified Indiana Business or determines any of the information to be inaccurate or misrepresented, a company’s
designation as a Qualified Indiana Business may be revoked and credits issued may be nullified at the IEDC’s sole discretion.
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