City Of Philadelphia Department Of Revenue Form - Renewal Application - Application Approval - Certification Of Non-Indebtedness To The City Of Philadelphia Page 2

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City of Philadelphia

FOR DEPARTMENT USE ONLY

Department of Revenue

Application No.

SECTION III

Attachments

The following information must be submitted with this application:

1) Attach a narrative description that itemizes the activities and projects in the current year. This shall include a listing of

completed economic development projects that delineate the economic development benefits and project budgets. In

addition it should specify the areas of economic distress that were specifically addressed with the tax credit funding.

Particular attention should be given to job creation and retention, both full and part time. Also include a brief description of

any other funds that were directly leveraged as a result of the tax credit funding.

2) Attach a budget that delineates how the tax credit funds in the current year were spent.

3) Attach a detailed description of the attributes which continue to make your community economically distressed.

4) Attach a detailed description of the scope of work which will be completed with the tax credit funds, which address one

or more of the issues identified in number three above, and which continue to make your community economically

distressed.

5) Attach a budget that delineates how the tax credit funds will be spent in the coming year.

6) Attach an executed copy of the Qualifying Community Development Corporation’s Certification of Compliance with all

Federal, State, and City Laws, Ordinances, and Resolutions and Certification of Non-Indebtedness to the City of

Philadelphia.

7) Attach a current list of QCDC’s board members.

SECTION IV

Certification: To be signed by an authorized company representative.

I hereby certify that all information contained in this document and attachments are true and correct to the best of my

knowledge. If I knowingly make a false statement to obtain the tax credit for contribution to a community development

corporation, I _____________________________________________________________ , may be subject to criminal

prosecution.

C o m p a n y a n d S i g n e r

Signature:

Date:

Print Name:

Representing: _______________________________________________

Address:

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