State Form 52341 - Qualified Indiana Business Application

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QUALIFIED INDIANA BUSINESS APPLICATION
INDIANA ECONOMIC DEVELOPMENT CORPORATION
VCI TAX CREDIT PROGRAM
State Form 52341 (R3 / 6-11)
One North Capitol Avenue, Suite 700
INDIANA ECONIMIC DEVELOPMENT CORPORATION (IEDC)
Indianapolis, Indiana 46204
VENTURE CAPITAL INVESTMENT (VCI) TAX CREDIT PROGRAM
APPLICANT INFORMATION
Name of company
Federal identification / tax number
Indiana identification / tax number
NAICS code
Structure (
)
S Corp
C Corp
LLC
LLP
LP
Other (
) ___________________________
Address
County
Main telephone number
Main facsimile number
Web address
(
)
(
)
Name of contact person
Title
Telephone number
Facsimile number
E-mail address
(
)
(
)
Is the address above the company’s headquarters?
Yes
No
Address
County
Main telephone number
Main facsimile number
E-mail address
(
)
(
)
Name
Federal identification / tax number
Indiana identification / tax number
Percentage of ownership
Affiliation / relationship to other owners / shareholders / members
Address
County
Main telephone number
Main facsimile number
Web / e-mail address
(
)
(
)
Name
Federal identification / tax number
Indiana identification / tax number
Percentage of ownership
Affiliation / relationship to other owners / shareholders / members
Address
County
Main telephone number
Main facsimile number
Web / e-mail address
(
)
(
)
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