Form 8874(K) - Application For Certification Of Qualified Equity Investments Eligible

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8874(K)
APPLICATION FOR CERTIFICATION OF QUALIFIED EQUITY INVESTMENTS ELIGIBLE
41A720-S80 (5-16)
FOR KENTUCKY NEW MARKETS DEVELOPMENT PROGRAM TAX CREDIT
Commonwealth of Kentucky
DEPARTMENT OF REVENUE
KRS 141.432 to 141.434
➤ See instructions.
A
B
C
Name of Qualified Community
Federal Identification Number
Kentucky Corporation/LLET
Development Entity (CDE)
Account Number (if applicable)
_
Number and Street
Telephone
City
State
Zip Code
Fax Number
D
E
F
Name of parent taxpayer, if CDE is included
Federal Identification Number
Kentucky Corporation/LLET
in a consolidated tax return
of parent, if applicable
Account Number of parent, if
applicable
_
G
Type of Entity of CDE:
¨ Corporation
¨ Limited Liability Pass-through Entity
¨ General Partnership
¨ Other
H
I
J
Submission Date of Application
Total Number of Taxpayers
Total Amount of Qualified
making Qualifed Equity Investments
Equity Investments for all Taxpayers
/
/
(the number should equal number
of entries on line 6)
$
Mo.
Day
Yr.
1. Has your entity been certified as a qualified community development entity (CDE) as provided by IRC §45D(c) by
the U.S. Department of Treasury, Community Development Financial Institutions Fund (CDFI Fund)?
Yes _____ No _____ Date Certified ___ ___ / ___ ___ / ___ ___ (Proof of current certification with the CDFI Fund that
would include the original certification by the CDFI Fund and all subsequent updates must be attached.)
2. Has your entity received a new markets tax credit (NMTC) allocation from the CDFI Fund which includes the
Commonwealth of Kentucky within the service area as set forth in such allocation agreement?
Yes _____ No _____ Date of the NMTC allocation ___ ___ / ___ ___ / ___ ___ (a copy must be attached)
3. Does your entity include the Commonwealth of Kentucky in its service area? Yes _____ No _____
4. Identify the service area of the CDE: _______________ county_______________ state _______________multi-state
_______________ national (attach map of the service area, articles of organization that describe the service area,
bylaws that describe the service area, or other documentation that describes the service area)
5. Provide information regarding the use of the proceeds from the qualified equity investments, including a description
of the qualified active low-income community business as provided by KRS 141.432(5).
6. List the name, taxpayer identifying number, type of investment (place an “X” in column to indicate whether debt or
equity), and the amount of the qualified equity investment to be made by each taxpayer:
Taxpayer
Type of
Purchase Price
Name
Identification
Investment
of the Qualified
Number
Equity Investment
Equity
Debt
Total Qualified Equity Investments for all taxpayers (this should equal the amount in Item J).
If additional space is needed, attach schedule listing the above information.

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