Form Rev 81 1018e - Biotechnology Products And Medical Device Application For Sales And Use Tax Deferral For Lessor 82.75 Rcw Page 2
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2
3
4Lessee information
Total Structure Costs
1. Name of Lessee:
11. Machinery & Equipment:
2. Mailing Address:
Date equipment is to be installed
3. Contact Person:
Purchase Price
4. Telephone Number:
Lease Contract Price
5. Department of Revenue Tax Reporting Number
Fair market value of previously owned
machinery and equipment that is new
Yes
No
to the State of Washington
6. Do the lessee and lessor have 100%
same ownership?
Total Machinery & Equipment Costs
7. If the answer to question 6 is "Yes", please provide
12. Total Costs
documentation to substantiate the relationship.
8. If the answer to question 6 is "No", has the lessor
13. Estimated Completion Date:
agreed by written contract to pass the economic
benefit of the deferral to the lessee?
Business Activity to be Conducted at this Facility
9. If the answer to question 8 is “Yes”, is the economic
burden of the deferral passed to the lessee no less than
If additional space is needed to answer question 14, please
the amount of tax deferred by the lessor and evidenced
attach additional pages.
by written documentation of the type of payment,
credit, or other financial arrangement between the
14. Describe the nature of lessee’s manufacturing activity at
lessor or owner of the qualified building and the lessee
this facility:
AND has the lessee signed the statement below
agreeing to complete the annual tax incentive survey
required by RCW 82.32.645?
Please have the lessee sign the following statement.
Failure to do so will prevent approval of the
application.
Biotechnology Product
I agree to file an annual tax incentive survey with the
15. Check the product(s) produced through the application
th
department of revenue each April 30
following for
of biotechnology used in the prevention, treatment, or
th
eight years, beginning with April 30
following the
cure of diseases or injuries to humans.
calendar year in which the investment project is
Virus ........................................................................
certified by the department as operationally complete.
Therapeutic Serum ..................................................
Name
Date____________
Title
Antibody .................................................................
Protein .....................................................................
(Please attach a completed Lessee’s Application, if
applicable, a copy of the signed lease agreement, and
Toxin .......................................................................
other written documentation in support of your answers
Antitoxin .................................................................
to question 8 and 9, if applicable.)
Vaccine ...................................................................
Blood .......................................................................
Estimated Investment Project Costs
Blood Component or Derivative .............................
Include only those costs that will be paid for by the applicant.
Allergenic Product ..................................................
10. Structure:
Analogous Product ..................................................
Date building permit will be issued
Yes
No
Construction of new structure(s)
16. Are you currently paying manufacturing
Leasehold improvements paid for by
or processor for hire business and
applicant
occupation tax on the above described
activity?
Expansion or renovation to expand
floor space or production capacity
17. If the answer to question 16 is "No" is
this a new manufacturing activity for
Construction of cogeneration facility
your business?
(continued next column)
REV 81 1018e (5/14/13)
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