Form Cat Cs - Commercial Activity Tax Credit Report Page 2

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Credit Schedule

(If credits are being claimed by members of a consolidated elected or combined taxpayer group, a separate schedule is required for

each entity that is claiming a credit.)

The CAT account number of the entity entitled to the credit may be different than that of the primary reporting entity.

Entity entitled to credit: Name

FEIN

CAT account number

Nonrefundable Credits

Credit Earned

Credits Claimed

Opening Unused

Closing Unused

During Current

Credit Balance

Reporting Period

1. Jobs retention credit

2. Qualiﬁ ed research expense credit

3. Research and development loan

repayment credit

4. Total

*Combine with credits being claimed by other entities in the group (if any) and carry this forward to the nonrefundable credits line on your

CAT return.

Must attach credit certiﬁ cate received from the Department of Development.

Refundable Credits

Must attach credit certiﬁ cate received from the Department of Development

Ohio motion picture credit............................................................................................................................................. 1.

Jobs creation credit...................................................................................................................................................... 2.

Jobs retention credit..................................................................................................................................................... 3.

Total of lines 1 through 3 to be carried forward to the refundable credits line of the CAT return .................................. 4.

Declaration and Signature

(an ofﬁ cer or managing agent of the corporation must sign this declaration)

I declare under penalties of perjury that this report (including any

use any of its money or property for or in aid of or opposition to

accompanying schedule or statement) has been examined by

a political party, a candidate for election or nomination to public

me and to the best of my knowledge and belief is a true, correct

ofﬁ ce, or a political action committee, legislation campaign fund,

and complete return and report, and that this corporation has not,

or organization that supports or opposes any such candidate or

during the preceding year, except as permitted by Ohio Revised