Form Afi - Angel Fund Investment Report -North Dakota Office Of State Tax Commissioner - 2011
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1Form
North Dakota Office of State Tax Commissioner
2011
AFI
Angel Fund Investment Report
Calendar Year
Part 1 - Certified angel fund information
Name of angel fund
Federal employer identification number (FEIN)
Address
State
Zip Code
City
Signature -
I declare that this form is correct and complete to the best of my knowledge and belief.
Date signed
Signature
Printed name of person signing form
Telephone number
E-mail address
Part 2 - Enterprise information - Include all enterprises within and without North Dakota in which the angel fund
made an investment from the first day of its original certification period through December 31, 2011.
Name of enterprise
Address of principal place of business
Initial year
If additional lines are needed, attach additional form(s).
Who must use this form
When and where to file
How to complete this form
The 2011 North Dakota Legislature
In Part 1, enter the name, address, and
This form must be completed and filed
passed legislation creating a new
federal employer identification number
on or before January 30, 2012. Mail
reporting requirement for North Dakota
(FEIN) that will be used on the angel
the completed from to:
angel funds certified under N.D.C.C.
fund's North Dakota income tax return.
Office of State Tax Commissioner
§ 57-38-01.26. Form AFI must be used
This form must be signed by a person
600 E. Boulevard Ave., Dept. 127
to report the name and the address of
authorized to act on behalf of the angel
Bismarck, ND 58505-0599
the principal place of business of each
fund. A telephone number and, if
enterprise within and without North
available, an e-mail address are
The angel fund should keep a copy of
Dakota in which the angel fund made
requested in case the Office of State
the completed form in its tax records.
an investment.
Tax Commissioner has any questions
about the completion of the form.
Where to get help
Form AFI must be filed for each
In Part 2, enter the name and the
calendar year in which it was certified
Phone
address of the principal place of
for any part of the year, including the
701.328.1247
business of each enterprise within and
year in which it ceases operations.
Speech or hearing impaired - call
without North Dakota in which the
Relay ND at 1.800.366.6888
angel fund made an investment from
Information disclosure - The law
the first day of its original certification
E-mail
authorizes the tax commissioner to
period through December 31, 2011.
individualtax@nd.gov
disclose to North Dakota's Legislative
This applies even if the original
Management the name of the angel
certification period began before 2011.
Web site
fund and the information in Part 2 of
If certified more than once, include all
this form.
certification periods. Also enter the
calendar year in which the initial
investment was made in the enterprise.
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