Form Int-4 - Notice Of Change Of Ownership, Interest, Or Participation Of Interest In Income Tax Capital Credit Project

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A
D
R
DEPARTMENT USE ONLY
LABAMA
EPARTMENT OF
EVENUE
FORM
CONTROL NUMBER
Notice of Change of Ownership,
INT-4
___________________
Interest, or Participation of Interest
12/01
in Income Tax Capital Credit Project
This form is used to report a change in investing companies, sale of project to another party, merger into another company, or any other change of ownership or assign-
ment of interest in the participants of the project entity. Notice is given by completing all portions of this form and the schedule of allocation. When completed, the form
will provide the Alabama Department of Revenue with the name of the current project entity and a complete list of current eligible participants of the capital credit project.
The project number originally assigned by the Alabama Deparment of Revenue must be indicated.
Capital Credit Qualifying Project Identification
Project Number:
NAICS Code:
Project Location:
Type of project:
New
Expansion
Small Business Addition
Headquarters Facility
Favored Geographic Area
State Docks
Date project was originally placed in service as filed on Form INT-2, line 4:
Actual project capital costs as originally filed on Form INT-2, line 6:
Project Information Prior to Change of Ownership, Interest, or Participation of Interest in Project
Project Entity:
Project Name:
Address:
FEIN:
City:
State:
ZIP:
Telephone No.: (
)
Project filing status:
LLC
Sole Proprietorship
C Corporation
S Corporation
Estate
Partnership
(
only one)
Project Information Subsequent to Change of Ownership, Interest, or Participation of Interest in Project
Effective date of change of ownership, interest, or participation of interest in project:
Description of the change (i.e., change of interest, merger, sale of project):
Project Entity:
Project Name:
Address:
FEIN:
City:
State:
ZIP:
Telephone No.: (
)
Project filing status:
LLC
Sole Proprietorship
C Corporation
S Corporation
Estate
Partnership
(
only one)
Contact person for capital credit and to whom all correspondence will be sent:
Use The Schedule Below To List All Current Participants Of The Project Entity.
Current Allocations of Capital Credit
A complete list of all participants in the project entity entitled to receive the Capital Credit must be provided. (Attach additional sheets if necessary.)
1.
Name:
3.
Name:
Address:
Address:
City:
State:
Zip:
City:
State:
Zip:
Social Security No. or FEIN:
Social Security No. or FEIN:
Percentage Allocation of Credit:
%
Percentage Allocation of Credit:
%
2.
Name:
4.
Name:
Address:
Address:
City:
State:
Zip:
City:
State:
Zip:
Social Security No. or FEIN:
Social Security No. or FEIN:
Percentage Allocation of Credit:
%
Percentage Allocation of Credit:
%
Under penalties of perjury, I declare that I am duly authorized to complete this form and that I have listed all the participants of the project
entity. I have examined the above statements and to the best of my knowledge and belief they are true, correct, and complete.
Your Signature:
Title:
Date:

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