Form Ap-214 - Texas Certified Capital Company Application Requesting Allocation Of Tax Credits
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2AP-214
(Rev.9-07/2)
TEXAS CERTIFIED CAPITAL COMPANY
APPLICATION REQUESTING ALLOCATION OF TAX CREDITS
1. Name of proposed Certified Capital Company (“CAPCO”)
2. Address - Street
City
State
ZIP code
3. Name of contact person
4. Phone number (Area code and number)
5. FAX number (Area code and number)
6. E-mail address
I hereby certify that the investor listed below has irrevocably committed to make an investment of certified capital to this certified
capital company as indicated below, and that such investment shall be used as prescribed in Chapter 4, Subchapter B, Texas Insurance
Code, and rule 34 TAC §3.833, Texas Administrative Code.
Printed name of officer of CAPCO
Title of officer of CAPCO
Signature of CAPCO officer
Date
1. Name of Certified Investor
2. Address - Street
City
State
ZIP code
3. Federal employer identification number (FEIN)
4. NAIC number
5. Amount of cash irrevocably committed
6. Nature of Certified Investor’s interest (Check one)
$
Equity interest in CAPCO
CAPCO’s qualified debt
7. Insurer’s affiliates. (Attach additional sheets as necessary.)
NAME OF INVESTOR’S INSURER AFFILIATES
FEDERAL EMPLOYER ID NUMBER (FEIN)
NAIC NUMBER
_____________________________________________________________________
______________________________________________
________________________
_____________________________________________________________________
______________________________________________
________________________
_____________________________________________________________________
______________________________________________
________________________
THE UNDERSIGNED OFFICER of _________________________________________________ , being duly sworn,
Certified Investor Taxpayer
hereby requests the subject certified capital company to apply to the Texas Comptroller of Public Accounts on its behalf
for an allocation of tax credits in the amount of the investment of certified capital indicated above. The UNDERSIGNED
OFFICER further certifies that an investment of certified capital will be made to the CAPCO in accordance with the
provisions of Chapter 4, Subchapter B, Texas Insurance Code, and 34 TAC §3.833, Texas Administrative Code.
____________________________________________
Signature
____________________________________________
Printed name and title
____________________________________________
Daytime phone (Area code and number)
State of _______________________________
County of ______________________________
Subscribed and sworn to before me this _____ day of _______________ , 20 _____ .
____________________________________________
(Notary Seal)
Signature of Notary Public
My commission expires __________________________ .
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