Form 8942 - Application For Certification Of Qualified Investments Eligible For Credits And Grants Under The Qualifying Therapeutic Discovery Project Program Page 2
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Form 8942 (6-2010)
Page
Certification and Grant Election Information (continued)
Part II
20
Yes
No
Will this project create and sustain (directly or indirectly) high-quality, high-paying jobs in the United States?
21
Enter the number of full-time and part-time employees in the United States whose work is directly billed to the project and the
average salaries of the employees in each category. See instructions.
Employees
Number of employees
Average salaries of the employees
a Full-time
b Part-time
22 a Enter the number of contractors in the United States paid for work on the project .
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b Enter the average monthly hours of the contractors entered on line 22a
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c Enter the average monthly compensation of the contractors entered on line 22a.
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23
Will this project advance United States competitiveness in the fields of life, biological, and medical
sciences? .
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Yes
No
24
As of the date this application is submitted, is the project active, terminated, or suspended? Check one.
Active
Terminated
Suspended
25
If the project is terminated or suspended for any of the failures below, check all boxes that apply.
The project failed a clinical trial.
The project failed a pre-clinical research milestone.
The project failed to secure FDA licensure.
If the applicant checked any of the boxes above, do not continue with this application.
26
Will the project produce a new or significantly improved technology, or a new application of or significant
improvement to existing technology, as compared to commercial technologies currently in service?
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Yes
No
27
Is the project expected to lead to the construction or use of a contract production facility in the United
States in the next 5 years? .
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Yes
No
Qualified Investment (see instructions)
Part III
Complete columns (a), (b), and (c), as
(a)
applicable. See instructions.
As of September 30, 2010
(b)
(c)
(tax year 2009 only)
Tax year 2009
Tax year 2010
Complete column (a) only for 2009 grant
(see instructions)
applications if the applicant's 2009 tax year ends
after the application date.
28
Qualified investment derived
from employee wages.
29
Qualified investment derived
from supplies and lab costs.
30
Qualified investment derived
from depreciable property.
31
Qualified investment derived
from third-party contractors.
32
Qualified investment derived
from other costs.
33
Amount in line 30 attributable to
qualified progress expenditures.
34
Total. Add lines 28 through 32 in
each column.
35
Qualified investment for which certification is requested. Add line 34 columns (b) and (c).
36
This application is for certification of qualified investment, related to a qualifying therapeutic discovery project, for (check only one):
Tax year beginning in 2009 only. Enter the ending date of the tax year .
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Tax year beginning in 2010 only. Enter the ending date of the tax year .
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Tax years beginning in 2009 and 2010. Enter the ending date of the tax year for 2009 .
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and for 2010 .
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Sign Here
Under penalties of perjury, I declare that I have examined this submission, including the accompanying documents, and, to the best of my knowledge and
belief, all of the facts contained herein are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which
Keep a copy
preparer has any knowledge.
of this form
for your
records.
Signature of Applicant
Date
Title
Date
Preparer’s SSN or PTIN
Paid
Preparer’s
Check if self-
signature
employed
Preparer’s
Firm’s name (or
EIN
Use Only
yours if self-employed),
address, and ZIP code
Phone no.
8942
Form
(6-2010)
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