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Virginia Department of Taxation

Form EDC

TAX YEAR ENDING

2601154 11/02

_____________, 20____

Taxpayer Application for Qualified Equity and

Subordinated Debt Investments Tax Credit

Submit this form by April 1. Credit must be approved before being claimed on your tax return. See instructions for details.

Name

Official Use Only

SSN, FEIN or Virginia Account Number

Req. $_________

Street address

App. $_________

City, State and ZIP Code

Date: _________

Entity Type: ____Individual ____Partnership ____LLC ____S Corporation

If you made a cash investment in a qualifying business in the form of qualified equity or subordinated debt, submit this application

with the Virginia Department of Taxation. The Department will determine the allowable credit amount. The credit is equal to 50% of

the amount of all qualifying investments made during the taxable year. The aggregate amount of credit that may be claimed per

taxpayer per year is limited to the amount of tax or $50,000, whichever is less. The credit is nonrefundable, however, excess credit

may be carried forward for up to fifteen years. The allowable credits will be prorated by the Department of Taxation if total annual

requests exceed $5 million. Penalties and forfeiture of this credit may apply if the equity investment is held for less than five years

following the year the credit is allocated or on any subordinated debt investment that is held for less than three years. IMPORTANT:

See instructions for details on when and where to submit. Submitting a late application will disqualify you for the credit.

PART I - BUSINESS ENTITY IDENTIFICATION

Complete a section for each qualifying investment. You must have a department issued QBA-C from each qualifying

business. Do not include investments in which you or any family members, or any entity affiliated with you, receives or has

received compensation from the qualified business in exchange for services provided to the business as an employee, officer,

director, manager, independent contractor or otherwise connected within one year before or after the date of investment.

Attach additional pages if needed.

1. Name of Qualified Business Entity:

2. Certificate Number from Form QBA-C provided by the qualified business:

3. Name and type of investment (i.e. equity or subordinated debt) ____________________________________________

Date Qualified Investment Made ______________________ Amount of Qualified Investment $___________________

Purchased from ________________________________

1. Name of Qualified Business Entity:

2. Certificate Number from Form QBA-C provided by the qualified business

3. Name and type of investment (i.e. equity or subordinated debt)

Date Qualified Investment Made ______________________ Amount of Qualified Investment $__________________

Purchased from ________________________________

PART II -TOTAL CREDIT REQUESTED

1. TOTAL QUALIFIED INVESTMENT (including any amounts listed on separate pages) $______________

2. Multiply TOTAL QUALIFIED INVESTMENT (line 1) amount by 0.5(50%) enter result here: $_______________

Under penalty of law, I have read and understand the limitations and restrictions for this credit.

Taxpayer Signature: _____________________________________ Title: __________________________________

Printed Name: __________________________________________ Date: ______________ Phone: ____________

Tax Preparer Name: ______________________________________Phone: ____________________

Address: _______________________________________________________________

_______________________________________________________________

Form Edc - Taxpayer Application For Qualified Equity And Subordinated Debt Investments Tax Credit

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