Form Rev-545ct - Pennsylvania Research And Development Tax Credit

Commonwealth of Pennsylvania

REV-545CT(5-04)PC

PENNSYLVANIA

PA DEPARTMENT OF REVENUE

RESEARCH AND DEVELOPMENT

BUREAU OF CORPORATION TAXES

TAXING DIVISION - R&D UNIT

TAX CREDIT

DEPT. 280703

HARRISBURG, PA 17128-0703

2004 APPLICATION

Account ID (Box Number/SSN)

Entity ID (EIN)

ENTITY INFORMATION - (PLEASE PRINT OR TYPE)

Entity Name

DUE DATE:

September 15, 2004

Street Address

Department Use Only

POST MARK DATE:

City or Town, State, and Zip Code

SEE REVERSE SIDE INSTRUCTIONS

BEFORE COMPLETING

CHECK BLOCK IF A "SMALL BUSINESS"

KOZ - SEE INSTRUCTIONS ON BACK

IF CLAIM IS AS A "SMALL BUSINESS" WITH TOTAL ASSETS OF LESS THAN $5,000,000 AT THE BEGINNING OR END OF THE YEAR

SUBMIT A BALANCE SHEET REFLECTING TOTAL ASSETS.

COMPUTATION OF CREDIT

1. Pennsylvania qualified Research & Development Expenditures:

Use Whole Dollars

Tax Year Beginning

Tax Year Ending

Actual

Annualized

MM/DD/YYYY

__ __/__ __/__ __ __ __ __ __/__ __/__ __ __ __ $__________________ . . . . . . . . . . . . . . . . . . . . . 1. $____________________

2. 50% of Line (1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. $____________________

3. Prior years' Pennsylvania Research & Development Expenditures:

Tax Year Beginning

Tax Year Ending

Actual

Annualized

MM/DD/YYYY

__ __/__ __/__ __ __ __

$__________________ 3A. $__________________

__ __/__ __/__ __ __ __

$__________________ 3B. $__________________

__ __/__ __/__ __ __ __

$__________________ 3C. $__________________

__ __/__ __/__ __ __ __

$__________________ 3D. $__________________

4. Total of prior years' Annualized Pennsylvania Research & Development Expenditures

(Sum of Annualized 3A, 3B, 3C, & 3D) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4. $____________________

5. Average of prior years' Pennsylvania Research & Development Expenditures

(Line (4) divided by number of base years in Line (3) with R&D Expenditures). . . . . . . . . . . . . . . . . . .5. $____________________

6. Line (1) Annualized minus the greater of Line (2) or Line (5). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6. $____________________

7. Tentative Pennsylvania Research & Development Credit (Line (6) x 10%). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. $____________________

SIGNATURE AND VERIFICATION

Under penalties of perjury, I declare that I have examined this return, including any accompanying schedules and statements, and to the best of my knowledge and belief it is true,

correct, and complete. THIS FORM MUST BE SIGNED BY A CORPORATE OFFICER.

SIGNATURE OF OFFICER OF COMPANY

TITLE

DATE

PRINT OFFICER'S NAME

TELEPHONE NUMBER

E-MAIL ADDRESS

(

)

NAME OF PREPARER

PREPARER'S ADDRESS

TELEPHONE NUMBER