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Form 8874(K) - Application For Certification Of Qualified Equity Investments Eligible For Kentucky New Markets Development Program Tax Credit Page 2

41A720-S80 (8874(K)) (11-10)

Commonwealth of Kentucky

DEPARTMENT OF REVENUE

7. Include a nonrefundable application fee of $1,000 with this application. Payment of the fee must be by cashier’s

check.

Under penalties of perjury, I declare that the applicant’s allocation agreement remains in effect and has not been

revoked or canceled by the CDFI Fund; and that I have examined the application, including all accompanying

documents and statements, and to the best of my knowledge and belief, it is true, correct and complete.

By: ________________________________________________

____________________________________________________

Signature of executive officer of CDE

Date

Print Name: _______________________________________

Title: ______________________________________________

Department of Revenue Use Only

The application is approved __________

The application is not approved (see attached explanation) __________

By: ___________________________________________

Date: _____________________

Mail to Department of Revenue, Division of Corporation Tax, Station 52, 501 High Street, Frankfort, KY 40601-2103.

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Form 8874(K) - Application For Certification Of Qualified Equity Investments Eligible For Kentucky New Markets Development Program Tax Credit Page 2