Form R-10609 - New Markets Tax Credit Application - Louisiana Department Of Revenue Page 2

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Calculation of Adjusted Purchase Price

Calculate the adjusted purchase price for all anniversary dates in accordance with Revenue Ruling 08-011 and the formula below, and

then place in table below. If an LLC or partnership, use a table for each member or partner.

Amount of QEI made on certain credit allowance

Amount of QEI on certain credit

date invested in Louisiana or to be invested

Adjusted Purchase price.

allowance date.

$______________

Amount of QEI made on certain

credit allowance date.

$______________

Na m e o f I nve sto r or I nve s to r Me m b er /Par tn er :

Credit Allowance Dates

Credit Amount

Allocated Percentage

Percentage Credit Amount

Na m e o f I nve sto r or I nve s to r Me m b er /Par tn er :

Credit Allowance Dates

Credit Amount

Allocated Percentage

Percentage Credit Amount

Na m e o f I nve sto r or I nve s to r Me m b er /Par tn er :

Credit Allowance Dates

Credit Amount

Allocated Percentage

Percentage Credit Amount

Na m e o f I nve sto r or I nve s to r Me m b er /Par tn er :

Credit Allowance Dates

Credit Amount

Allocated Percentage

Percentage Credit Amount

I attest and affirm that the information detailed in this application is true and accurate to the best of my knowledge and I understand that upon the

indication of a misrepresentation of the facts therein I am subject to legal and tax consequences, including a total recapture of credits granted as a result

of the misrepresentation.

Print Taxpayer Name

Print Taxpayer Representative

Taxpayer Representative or Taxpayer Signature

Date

(mm/dd/yyyy)

Note: This application will be processed in the order received. Once this application is processed, you will receive a New Markets

Certification Form. Use the New Markets Certification Form to claim and transfer the New Markets Tax Credit. For more information on

how to claim and transfer this credit, refer to the proposed regulation LAC 61:1.1911 available on the Department’s website.

Submit this application to: NewMarketTax.CreditApplication@la.gov