Form Edc - Taxpayer Application For The Qualified Equity And Subordinated Debt Investments Tax Credit

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Form EDC
Virginia Department of Taxation
Tax Year Ending
Taxpayer Application for the Qualified Equity
, 20
and Subordinated Debt Investments Tax Credit
Submit this form by April 1. Credit must be approved before being claimed on your tax return. See instructions for details.
Name (One name per application)
SSN or FEIN (One per application)
Street Address
Phone Number
City, State and ZIP Code
Email
Entity Type: (Check one)
Individual
Partnership
LLC
S Corporation
Trust
If you made a cash investment in a qualifying business in the form of qualified equity or subordinated debt, submit this application to
the Department. The Department will determine the allowable credit amount. The credit is equal to 50% of the amount of all qualifying
investments made during the taxable year. The aggregate amount of credit that may be claimed per taxpayer per year is limited to the amount
of tax or $50,000, whichever is less. The credit is nonrefundable; however, excess credit may be carried forward for up to 15 years. The
Department will prorate the allowable credits if total annual requests exceed $4.5 million. Penalties and forfeiture of this credit may apply
if the equity investment is held for less than 3 years following the year the credit is allocated or on any subordinated debt investment that
is held for less than 3 years. IMPORTANT: See the instructions for details on when and where to submit the application. No application
received after April 1st will be eligible for the credit.
PART I - BUSINESS ENTITY IDENTIFICATION
Complete this section for each qualifying investment. You must have a Department-issued qualified business certification from each
qualifying business. Do not include investments in which you or any family members, or any entity affiliated with you, receives or has
received compensation from the qualified business in exchange for services provided to the business as an employee, officer, director,
manager, independent contractor or otherwise in connection with or within one year before or after the date of such investment. Attach
additional pages if needed.
1. Name of Qualified Business Entity
2. Certificate Number from Form QBA Provided by the Qualified Business
3. Name and Type of Investment (i.e. equity or subordinated debt)
.00
Date Qualified Investment Made
Amount of Qualified Investment $
1. Name of Qualified Business Entity
2. Certificate Number from Form QBA Provided by the Qualified Business
3. Name and Type of Investment (i.e. equity or subordinated debt)
.00
Date Qualified Investment Made
Amount of Qualified Investment $
PART II - TOTAL CREDIT REQUESTED
1. TOTAL QUALIFIED INVESTMENT (including any amounts listed on separate pages)
$
.00
2. Multiply Total Qualified Investment (Line 1) Amount by 0.5 (50%), Enter Result Here
$
.00
3. Total Number of Qualified Investments
PART III - DECLARATION
Under penalty of law, I have read and understand the limitations and restrictions for this credit.
Taxpayer Signature
Title
Printed Name
Date
Phone
Authorized Representative
Phone
Address
Email
Va. Dept. of Taxation
2601154
EDC
Rev 08/13

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