Form Loa - Loan-Out Affidavit/allocation - 2014 Page 2
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1
2
3Payments to Loan-Out Company
1 Total amount paid by production company to personal service/loan-out company for overall production. . . . . . . . . . . . . . . . . . . 1
2 Total amount paid by production company to personal service/loan-out company for qualifying Massachusetts payroll/
production credit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3 Do all payments on line 2 by production company to this loan-out constitute Massachusetts source income relating to services for this production?
Yes
No
4 Is the company registered for Massachusetts motion picture performer withholding tax?
Yes
No
5 Total amount of Massachusetts withholding tax remitted to Massachusetts relating to this loan-out company. . . . . . . . . . . . . . . 5
Dates the personal service/loan-out company performed service on this production in Massachusetts
6
Start date:
End date:
Date(s) withholding payment remitted to Massachusetts Department of Revenue
7
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
Mail to: Massachusetts Department of Revenue, Audit Division, 200 Arlington Street, Room 4300, Chelsea, MA 02150, attn.: Film Credit Unit.
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