Form Qba - Application For Designation As A Qualified Business For The Qualified Equity And Subordinated Debt Investments Tax Credit
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4Form QBA
Application for Designation as a Qualified
Business for the Qualified Equity and
Subordinated Debt Investments Tax Credit
See the instructions for when and where to apply.
Name (Please Print)
FEIN
Trading As
Date Incorporated
Street Address
For Calendar Year
City, State and ZIP Code
NAICS Code
Office Use Only
Use this form to apply for designation as a qualified business for purposes of issuing equity or subordinated debt instruments which qualify for the Virginia
Qualified Equity and Subordinated Debt Investments Tax Credit. IMPORTANT: The Form QBA does not have to be filed prior to making issuances. Title
23 of the Virginia Administrative Code (VAC) 10-110-225 et seq. provide regulations on this credit. Additionally, see instructions for investor information.
Business Entity Identification: See the definition of “Qualified Business” in the instructions, Va. Code § 58.1-339.4, or
23 VAC 10-110-225 et seq.
Type (check one):
C Corporation
S Corporation
Partnership
Limited Liability Company (LLC)
Business Criteria (check one):
Advanced Computing
Advanced Materials
Advanced Manufacturing
Agricultural Technologies
Biotechnology
Electronic Device Technology
Energy
Environmental Technology
Information Technology
Medical Device Technology
Nanotechnology
Any Similar Technology-Related Field
Describe:
1. Was your business created to commercialize research
developed at or in partnership with an institution of higher
education?
Yes
No
If yes, what is the name of the institution?
2. Is its principal office or facility in Virginia?
Yes
No If No, STOP; the business does not qualify
3. Is Virginia where the business entity is primarily engaged
in business or does substantially all of its production?
Yes
No If No, STOP; the business does not qualify
4. Were the business entity’s annual gross revenues for
the most recent fiscal year $3 million or less?
Yes
No If No, STOP; the business does not qualify
If yes, what were the annual gross revenues?
$
5. Has the business obtained, during its existence, more
than $3 million in aggregate gross cash proceeds for the
issuance of its equity or debt investments (not including
commercial loans from charted banking or savings and
Yes If Yes, STOP; the business does not qualify
loan institutions)?
6. Provide a detailed description of the type of business or activities in which the entity is primarily engaged or primarily
organized to engage (attach additional pages if necessary).
Va. Dept. of Taxation
QBA W 2601695 Rev 08/13
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