Form Loa - Loan-Out Affidavit/allocation - 2014
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32014
Form LOA
Loan-Out Affidavit /Allocation
Massachusetts
Department of
Revenue
Production company is required to complete and submit a separate loan-out affidavit for every personal service or loan-out company included on
the film credit application. Failure by production company to fully complete and submit a fully signed loan-out affidavit for a personal service or
loan-out company will result in disallowance of the credit claimed in relation to such personal service or loan-out company. To be valid and ac-
cepted, this form must be signed by an authorized representative from the loan-out company, the actor/performer and the production company.
General Information
Production company name
Federal Identification number
Mailing address
City/Town
State
Zip
Name of production
Massachusetts production start date
Massachusetts production end date
Personal Service/Loan-Out Company Information
Company name
Federal Identification number
Business address
City/Town
State
Zip
Mailing address (if different)
City/Town
State
Zip
Name of authorized representative
Title
Telephone
E-mail
Massachusetts start date
Massachusetts end date
Is company registered with Massachusetts Secretary of State to do business in Massachusetts?
Yes
No
Is company registered with Massachusetts Department of Revenue to file and pay taxes?
Yes
No
If the answer to either of these is No, the company will be required to register with the Massachusetts Secretary of State and Department of Revenue.
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
Name
Date
Attach additional sheets if more than one actor/performer is provided by this loan-out.
Actor/Performer Information.
Name of actor/performer providing loan-out services
Social Security number
Residential address
City/Town
State
Zip
Mailing address (if different)
City/Town
State
Zip
Massachusetts start date
Massachusetts end date
Is actor/performer registered with Massachusetts Department of Revenue to file and pay taxes?
Yes
No
If No, the actor/performer will be required to register with the Massachusetts Department of Revenue and file a personal income tax return.
I declare under the pains and penalties of perjury that to the best of my knowledge, the information contained herein is accurate and complete.
I also understand and agree to comply with the Motion Picture Production Company Withholding Regulation 830 CMR 62B.2.3 Sec. 5(b).
Signature
Name
Date
Be sure to complete page 2.
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