Form 775n - Nebraska Employment And Investment Growth Act Credit Computation Page 5

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FORM

NEBRASKA SCHEDULE III —

Changes Within Current Employment and

775N

Investment Growth Act Project

Name as Shown on Form 775N

Project Name

Nebraska Identification Number

Date of Application

SECTION 1:

Addition of New Location to Project

1 A Is there a new location included in the project? ....................................................................................

YES

B What is the new address?

2 Does the application include all locations in the state? ..............................................................................

YES

3 Is the location interdependent with the prior project locations? .................................................................

YES

How?

SECTION 2:

Change in Ownership of Project

4 Has the controlling ownership of applicant changed? ................................................................................

YES

If Yes, please explain.

5 Is the applicant named in the Employment and Investment Growth Act agreement a corporation? ..........

YES

If No, it is not necessary to complete the rest of this section.

6 Does Paragraph 1 of the Employment and Investment Growth Agreement include unitary group

members?

............................................................................................................................................

YES

If No, it is not necessary to complete the rest of this section.

SECTION 3:

Addition of New Entity or Acquisition of Assets

7 Was there a purchase of the assets of another business? ........................................................................

YES

If Yes, please identify.

Please complete questions 9B, 10 and 11 of this section and questions 5 and 6 of Section 2.

8 Is there a new corporation, joint venture, limited liability company, or partnership that is doing business

at the project? ............................................................................................................................................

YES

If Yes, please identify.

Please complete questions 9 through 11 of this section and questions 5 and 6 of Section 2.

9 A Is the entity owned at least fifty percent by corporate members of the unitary group? ........................

YES

If Yes, please identify owners and percent of ownership.

B Is the new business engaged in a qualifying activity? ..........................................................................

YES

Describe the activity:

C Is the entity unitary with the corporate members of the unitary group? ................................................

YES

10 Was the base year adjusted for the full-time equivalent employees which worked for the new entity for

the 12-month period of time prior to the date of acquisition? .....................................................................

YES

11 Was the investment placed in service prior to the date of acquisition excluded from the investment

calculations? ............................................................................................................................................

YES

NOTE: If the response to line 7 includes more than one entity, please attach a schedule which provides a response to questions

5 through 9 for each of the entities.

ATTACH THIS PAGE TO YOUR NEBRASKA INCOME TAX RETURN