Form Rev 81 1018e - Biotechnology Products And Medical Device Application For Sales And Use Tax Deferral For Lessor 82.75 Rcw Page 3

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Reception Area
%
Medical Devices at this Facility
Research & Development
%
18. What type of medical device will be designed or
developed including any component, part, or accessory?
Sales & Marketing
%
Check all that apply.
Warehouse
%
Instrument ...............................................................
Other (please describe)
%
Apparatus ................................................................
Total
100 %
Implement ...............................................................
Machine ...................................................................
Contrivance .............................................................
Lessee Employment Information
Implant ....................................................................
25. Average Number of Full Time Equivalents (FTEs) for
In Vitro Reagent ......................................................
Previous Calendar Year.
(1820 annualized hours worked = 1 FTE):
Other Similar or Related Article .............................
Entire Business:
Explain
At This Facility:
26. Estimated or actual number of
new FTEs as a result of this
Yes
No
project:
19. Is the medical device recognized in the
27. Estimated or actual wages of FTE’s related to this project:
national formulary, United States
pharmacopoeia, or any supplement to
them?
20. Is the medical device intended for use
in the diagnosis of disease, or in the
cure, mitigation, treatment, or
Use of Facility
prevention of disease or other
All businesses must maintain a qualified activity at the site of
conditions in human beings or animals?
the investment project for the year in which the investment
project is certified as operationally complete, plus seven
21. Is the medical device intended to affect
additional years.
the structure of any function of the
Yes
No
body of human beings or other animals,
which cannot be achieved through
28. Do you plan to operate this investment
chemical action and which cannot be
project in a qualified manner for 8 years
achieved by metabolizing?
from the time the project is complete?
22. Are you currently paying manufacturing
29. If the answer to question 28 is “No”,
or processor for hire business and
how long do you plan to operate this
occupation tax on the above described
investment project with qualified use?
activity?
If the manufacturing or research and development activity is
23. If the answer to question 22 is “No,” is
not maintained, all or a portion of the deferred taxes
this a new manufacturing activity for
outstanding for this investment will be immediately due. The
your business?
department will assess interest at the rate provided for
delinquent excise taxes, but not penalties, retroactively to the
date of the deferral.
Apportionment of Structure
If the facility is used partly for research and development and
Audit Records Location
partly for other purposes, the applicable tax deferral shall be
determined by apportioning the costs of construction.
If your application is approved, a deferral certificate will be
issued using the estimates from your application. Upon
24. Percentage of facility devoted to:
completion of the project, an auditor will verify that you are
Accounting/Payroll
%
performing qualified activities at this facility. They will also
Administration
%
verify that the approved percentage of your structure and
Cafeteria
%
100% of the machinery and equipment are eligible for the
deferral. The auditor may adjust the allowable deferral based
Common Areas
%
on his or her findings.
Conference & Training Rooms
%
Customer Service
%
To minimize inconvenience and the time it takes to complete
an audit, please have the following records for the audit
Manufacturing
%
period available for your meeting with the auditor:
Pilot Scale Manufacturing
%
(continued next column)
(continued next page)
REV 81 1018e (5/14/13)

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