Form Rev 81 1012e - High Technology Application For Sales And Use Tax Deferral For Lessor 82.63 Rcw - 2013 Page 2
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311. Machinery & Equipment:
Lessee information
1. Name of Lessee:
Date equipment is to be installed
2. Mailing Address:
Purchase Price
3. Contact Person:
Lease Contract Price
4. Phone Number:
Fair market value of previously
5. Department of Revenue Tax Reporting Account
owned machinery and equipment
that is new to the State of
Number:
Washington
Yes
No
6. Do the lessee and lessor have 100%
Total Machinery & Equipment
same ownership?
Costs
7. If the answer to question 6 is "Yes", please provide
documentation to substantiate the relationship.
12. Total Costs
8. If the answer to question 6 is "No", has the lessor
agreed by written contract to pass the economic
benefit of the deferral to the lessee?
13. Estimated Completion Date:
9. If the answer to question 8 is “Yes”, is the economic
benefit of the deferral passed to the lessee no less than
Business Activity to be Conducted at this Facility
the amount of the tax deferred by the lessor and
If additional space is needed to answer questions 13 and
evidenced by written documentation of the type of
14, please attach additional pages.
payment, credit, or other financial arrangement
between the lessor or owner of the qualified building
14. Describe the nature of lessee's research and
and the lessee AND has the lessee signed the
development activities at this facility:
statement below agreeing to complete the annual tax
incentive survey required by RCW 82.63.020?
Please have the lessee sign the following statement.
Failure to do so will prevent approval of the
application.
15. Describe the nature of lessee’s pilot scale
manufacturing activity at this facility:
I agree to file an annual tax incentive survey with the
th
Department of Revenue each April 30
for eight
years, beginning with the first calendar year after the
calendar year in which the investment project is
certified by the department as operationally complete.
Name
Apportionment of Structure
Signature
If the facility is used partly for research and development and
Title
partly for other purposes, the applicable tax deferral shall be
Date
determined by apportioning the costs of construction.
16. Percentage of facility devoted to:
(Please attach a completed Lessee's Application, if
applicable, a copy of the lease agreement and other
Accounting/Payroll
%
written documentation in support of your answers to
Administration
%
question 8 and 9, if applicable)
Cafeteria
%
Common Areas
%
Estimated Investment Project Costs
Conference & Training Rooms
%
Please include only those costs that will be paid for by the
applicant.
Customer Service
%
Manufacturing
%
10. Structure:
Offices used by direct line
Date building permit will be issued
supervisors or other managers
who oversee the research &
Construction of new structure(s)
development process
%
Leasehold improvements paid for by
Reception Area
%
applicant
Research & Development
%
Expansion or renovation to expand
Sales & Marketing
%
floor space or production capacity
Warehouse
%
Construction of cogeneration facility
Other (please describe)
%
Total Structure Costs
Total
100 %
(continued in next column)
REV 81 1012e (5/14/13)
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