Angel Investment Tax Credit Application Form Page 2
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5Answer the following questions about the small business.
‡ Yes ‡ No
Is the small business primarily engaged in or organized as any of the following
types of businesses: Credit or finance services, including banks, savings and loan
associations, credit unions, small loan companies or title loan companies;
financial brokering or investment; professional services, including accounting,
legal services, engineering and any other service the practice of which requires a
license; insurance; real estate; construction or construction contracting;
consulting or brokering; mining; wholesale or retail trade; providing utility service,
including water, sewerage, electricity, natural gas, propane or butane; publishing,
including publishing newspapers or other periodicals; broadcasting; or providing
internet operating services?
‡ Yes ‡ No
Has the small business issued securities registered pursuant to Section 6 of the
federal Securities Act of 1933, as amended?
‡ Yes ‡ No
Has the small business issued securities traded on a national securities
exchange?
‡ Yes ‡ No
Is the small business subject to reporting requirements of the federal Securities
Exchange Act of 1934, as amended?
‡ Yes ‡ No
Is the small business registered pursuant to the federal Investment Company Act
of 1940, as amended, at the time of the investment?
‡ Yes ‡ No
Does the small business have 100 or fewer employees calculated on a full-time
equivalent basis at the time of the investment?
‡ Yes ‡ No
Does the small business have gross revenues in excess of five million dollars in
any fiscal year ending on or before the date of the investment?
1. Describe the principal business activity performed by the small business that qualifies the small
business as an eligible investment pursuant to the angel investment tax credit?
2. Enter the physical address where the qualifying principal business activity described above is
performed. If the qualifying business activity is performed in more than one location, enter all locations. If
more space is needed, include an attached statement.
New Mexico Economic Development Department
Page 2
Int. 7/24/2012
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