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DTF-620

New York State Department of Taxation and Finance

Application for Certification of a

(Revised 9/12)

Qualified Emerging Technology

Company

This application is for the certification period:

Tax Law — Articles 9-A and 22

beginning

ending

Part 1— Business information

Department use only

(all applicants must complete this section)

Print or type

1 Legal name

2 Trade name/DBA

( if different from line 1 )

3 Address of business in New York State

City

State

ZIP code

( number and street )

4 Mailing address

City

State

ZIP code

( if different from business address )

5 County

6 Business telephone number

7 Date business began or will begin in NYS

( place of business in New York State )

( include area code )

8 Federal employer identification number

9 Type of organization:

( mark an X in one box )

Corporation

Partnership

LLC

Other (specify)

10 I authorize the Commissioner of Taxation and Finance to disclose publicly that the above

company is a certified qualified emerging technology company (QETC) for the certification

period shown on this application, if the company so qualifies. The disclosure of information

may include the information shown on lines 1, 2, 3, and 4 of this application

. ........... Yes

( mark an X in one box )

Part 2 — Eligibility requirements

(mark an X in the appropriate box; see instructions)

11 Is the company located in New York State? ............................................................................................... Yes

12 Are the total annual product sales of the company $10,000,000 or less? .................................................. Yes

If you answered Yes to questions 11 and 12, continue with line 13 to see if you are eligible to be certified as a QETC under Category 1.

If you answered No to either question 11 or 12, you are not eligible to be certified as a QETC and should not complete this application.

Category 1 — Primary products or services

13 Does the company develop or create products or services that are classified as emerging technologies? ... Yes

If Yes, enter a description of the company’s emerging technology products or services:

14 Enter gross receipts or sales from the company’s emerging technology products or

services described on line 13 ....................................................................................................................... 14.

15 Enter total gross receipts or sales from all the company’s products or services ............................................ 15.

If line 15 is zero, skip lines 16 and 17 and continue with line 18.

If line 15 is greater than zero, continue with line 16.

16 Divide line 14 by line 15 and enter result as a percentage .............................................................................. 16.

17 Is the percentage on line 16 greater than 50%? ......................................................................................... Yes

If you answered Yes to questions 13 and 17, you are eligible to be certified as a QETC under Category 1. Sign the application in the

certification area and mail it to the address shown on page 2. If you answered No to either question 13 or 17, continue with line 18.

Form Dtf-620 - Application For Certification Of A Qualified Emerging Technology Company

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