Fillable Form R-10609 - New Markets Tax Credit Application (Page 2 of 2) in pdf

Form R-10609 - New Markets Tax Credit Application Page 2

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Complete Form R-10609 - New Markets Tax Credit Application with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

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Calculation of Adjusted Purchase Price

Calculate the adjusted purchase price for all anniversary dates in accordance with Revenue Ruling 08-011 and the formula below, and

then place in table below. If an LLC or partnership, use a table for each member or partner.

Amount of QLICI made on certain credit allow-

Amount of QLICI on certain credit

ance date invested in Louisiana or to be invested

Adjusted Purchase price.

allowance date.

$______________

Amount of QLICI made on certain

credit allowance date.

$______________

Na m e o f I nve sto r or I nve s to r Me m b er /Par tn er :

Credit Allowance Date

Credit Amount

Allocated Percentage

Na m e o f I nve sto r or I nve s to r Me m b er /Par tn er :

Credit Allowance Date

Credit Amount

Allocated Percentage

Na m e o f I nve sto r or I nve s to r Me m b er /Par tn er :

Credit Allowance Date

Credit Amount

Allocated Percentage

Na m e o f I nve sto r or I nve s to r Me m b er /Par tn er :

Credit Allowance Date

Credit Amount

Allocated Percentage

I attest and affirm that the information detailed in this application is true and accurate to the best of my knowledge and I understand that upon the

indication of a misrepresentation of the facts therein I am subject to legal and tax consequences, including a total recapture of credits granted as a result

of the misrepresentation.

Print Taxpayer Name

Print Taxpayer Representative

Taxpayer Representative or Taxpayer Signature

Date

(mm/dd/yyyy)

Note: This application will be processed in the order received. Once this application is processed, you will receive a New Markets Tax

Credit Summary Sheet. Use the New Markets Tax Credit Summary Sheet to claim and transfer the New Markets Tax Credit. For additional

information regarding the New Markets credit, contact the Special Programs Division at 225 219 2200.

Submit this application to: NewMarketTax.CreditApplication@la.gov