Form 0405-575 - Salmon Product Development Credit Pre-Qualification Form
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1Alaska
575
Salmon Product Development Credit
Pre-qualification Form
Fisheries Business License Number
SSN
EIN
Individual or Corporate Name
Tax Year of Proposed Investment
Facility Location
Contact Person
or Vessel Name
Mailing Address
Phone Number
Fax Number
City
State
Zip Code
Email Address
Total Estimated Cost of Proposed Investment - $
You must submit the following information along with this form before your request for
pre-qualification can be processed:
1. A detailed listing of the equipment to be purchased along with a description of what the equipment does. For
each piece of equipment, include the name of the manufacturer and the model number.
2. The estimated cost of each piece of equipment, including installation, supported by a price list or quote from
the manufacturer or seller.
3. A detailed description of the value-added salmon product(s), non-value-added salmon product(s) and non-
salmon product(s) the equipment will be producing.
4. An estimate (in pounds) of value-added salmon product(s), non-value-added salmon product(s) and non-
salmon product(s) to be produced in the first tax year by each piece of equipment upon which you wish to
claim a salmon credit.
Will you be applying for or receiving a grant to finance a portion of the total cost of the proposed investment?
YES
NO
I agree under penalty of unsworn falsification that this pre-qualification filing (including all accompanying attachments) has
been examined by me and, to the best of my knowledge, is true, correct and complete. I affirm that the equipment items
referenced will be purchased new with no previous use, will first be placed in service in Alaska and shall remain in Alaska,
and will be used predominantly to produce a value added salmon product beyond headed and gutted. I understand that
the Department of Revenue reserves the right to audit all accounts related to this salmon product development credit pre-
qualification filing.
Officer’s Signature
Printed Name
Title
Date
For Department Use Only
By
Title
Date
Approved
Disapproved
575
Mail to: Alaska Department of Revenue, PO Box 110420, Juneau AK 99811-0420
0405-575 Rev 12/12
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