Form It-Hq - Application For Georgia Headquarters Job Tax Credit Page 6
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IT-HQ
(REV 8/09)
I. CERTIFICATION BY APPLICATION
Applicant hereby certifies that all information contained above and in exhibits attached hereto are true
to his/her best knowledge and belief and are submitted for the purpose of obtaining certification from the Panel.
Date: ____________________
Applicant:________________________________________
MM/DD/YY
By: _____________________________________________
Signature of Authorized Officer
Title: ____________________________________________
Phone Number: ____________________________________
(000) 000-0000
Subscribed and sworn to before me, a Notary Public in and for said County and State, this____day of ______, 20__.
My commission expi
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Resident of ______________________________ County
State of _________________________________
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