Form 8874(K) - Application For Certification Of Qualified Equity Investments Eligible Page 2
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341A720-S80 (8874(K)) (5-15)
Commonwealth of Kentucky
DEPARTMENT OF REVENUE
7. Include a nonrefundable application fee of $1,000 with this application. Payment of the fee must be by cashier’s
check. A separate check must be issued for the nonrefundable application fee.
8. Include a refundable performance fee with this application equal to one-half of one percent (0.5%) of the qualified
equity investment requested to be certified, not to exceed $500,000. Payment of the fee must be by cashier’s
check. A separate check must be issued for the refundable performance fee.
Under penalties of perjury, I declare that the applicant’s allocation agreement remains in effect and has not been
revoked or canceled by the CDFI Fund; and that I have examined the application, including all accompanying
documents and statements, and to the best of my knowledge and belief, it is true, correct and complete.
By: ________________________________________________
____________________________________________________
Signature of executive officer of CDE
Date
Print Name: _______________________________________
Title: ______________________________________________
Department of Revenue Use Only
The application is approved __________
The application is not approved (see attached explanation) __________
By: ___________________________________________
Date: _____________________
Mail to Department of Revenue, Division of Corporation Tax, Station 52, 501 High Street, Frankfort, KY 40601-2103.
Page 2
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