Form Mdcta - Medical Device Credit Transfer Application - 2014

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2014
Form MDCTA
Medical Device Credit
Transfer Application
Massachusetts
Department of
Revenue
For calendar year 2014 or taxable year beginning
and ending
Medical device company name
Federal Identification or Social Security number
Mailing address
City/Town
State
Zip
Name of contact person
Telephone
E-mail address
1 Type of medical device company:
Corporation 
Trust 
Partnership 
Sole proprietorship 
LLC 
Other
2 Medical device credit amount eligible for transfer (amount on line 4 of Form MDCC unused by the medical device
company/transferor). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3 Certificate number issued by the Department of Revenue with respect to amount shown in line 2 above (from line 3
of Form MDCC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
4 Amount of medical device credit in line 2 above to be transferred with this application. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
5 Amount of financial assistance provided . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
If the financial assistance is other than in cash, please explain:
6 Date(s) financial assistance provided . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
7 Describe the Massachusetts use(s) to which the private financial assistance will be put:
Name of purchasing company
Federal Identification or Social Security number
Mailing address
City/Town
State
Zip
I declare under the pains and penalties of perjury that to the best of my knowledge, the information contained herein is accurate and complete.
Signature
Title of authortized representative
Date
Mail to: Massachusetts Department of Revenue, Audit Division, 200 Arlington Street, Room 4300, Chelsea, MA 02150, attn.: Medical Device Unit.
A copy of Form MDCC must be enclosed with this application.
On this
day of
, 20
, before me, the undersigned notary public, personally appeared
, provided to me through
satisfactory evidence of identification, which was
, to be the person whose name was signed above, and who swored or affirmed to me
that the private financial assistance specified in line 5 above has been provided.
Signature of notary public
Date of expiration of commission
Notary seal

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