Form D-499 - Application For Tax Credit For Qualified Business Investments

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D-499
Application for Tax Credit for
Qualified Business Investments
Web
8-13
North Carolina Department of Revenue
For investments made in 2013 to be claimed on income tax return for calendar year 2014
or for fiscal year beginning
, 2014, ending
, 2015
To be eligible for this credit, you must file this application with the Secretary of Revenue. The application should be filed on or before April 15,
2014, and no later than October 15, 2014. An application filed after October 15, 2014 will not be accepted. Do not attach this application to
your North Carolina income tax return. The application must be mailed separately to the address at the bottom of this form. See section B
on reverse for additional application requirements. Taxpayers will receive notification of approval of the credit claimed prior to the end of the calendar
year. A copy of the approval notification must be filed with the income tax return on which the credit is claimed. List the name(s) of each organization
in which you made a qualifying business investment. Attach additional schedules if necessary.
You must submit the following additional documentation with this application:
Evidence of your investment in the qualified business, including a copy of any stock certificate(s) or subordinated debt instrument(s) issued by
the business, and copies of canceled check(s) or other documents which verify your investment.
Certificate of Qualified Status for each organization for which credit is claimed.
The credit is not allowable if, within three years after the investment was made, you, your spouse, parent, brother, sister, child, or an employee of any
of these individuals, or a business controlled by any of these individuals, provided services of any nature to the qualified business for compensation,
whether as an employee, a contractor, or otherwise. For other conditions that result in forfeiture of the credit, see section G on reverse.
Name
SSN or FEIN
Address
Office Use Only
City
State
Zip Code
Credit claimed by (fill in circle):
Individual - IMPORTANT
1.
(If you also made an investment through a pass-through entity, you must provide a schedule with this
application identifying the name and FEIN of each pass-through entity.)
Pass-Through Entity
2.
(Pass-through entities must provide a schedule with this application identifying each person to whom the credit will
be passed, including the full name, address, identifying number, owner’s percentage share, and amount of credit.)
.00
3.
Date and amount invested in a Qualified Business Venture
(
)
3.
__________________
...........................
Date of Investment
Name of Qualified Business Venture
.00
4.
Date and amount invested in a Qualified Grantee Business
(
)
4.
_________________
...........................
Date of Investment
Name of Qualified Grantee Business
.00
5.
Date and amount invested in a Qualified Licensee Business
(
)
5.
_________________
...........................
Date of Investment
Name of Qualified Licensee Business
.00
6.
Add lines 3, 4, and 5 ....................................................................................................................................
6.
.00
7.
Tax Credit (Multiply amount on line 6 by 25% and enter credit - not to exceed $750,000 for
pass-through entities or $50,000 for individuals) ......................................................................................... 7.
If prepared by a person other than taxpayer, this certification is based on all
I certify that, to the best of my knowledge, this return is accurate and complete.
I also certify that I am not a participant in the operation of the qualified business
information of which the preparer has any knowledge.
as described in the General Information on the reverse under
G. Forfeiture of Credit.
Sign
Signature of Applicant(s)
Date
Signature of authorized agent
Date
Here
Agent’s firm and telephone number
Applicant’s telephone number (optional)
MAIL TO: NC Department of Revenue, Income Tax Division - Personal Taxes Section, Post Office Box 871, Raleigh, NC 27602-0871

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