Form Qba - Application For Designation As A Qualified Business For The Qualified Equity And Subordinated Debt Investments Tax Credit Page 2

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Form QBA
Application for Designation as a Qualified
Business for the Qualified Equity and
Page 2
Subordinated Debt Investments Tax Credit
Issuance Information
Describe the type of instrument the business entity is planning to issue for the purposes of this tax credit.
Type of Instrument
Estimated Amount
Anticipated Date of First Issuance
Equity
$:
Date:
Subordinated Debt
$:
Date:
Declaration
I, the undersigned officer or other person authorized to act on behalf of the business entity, have read and understand
the limitations and restrictions set forth for this application and the associated tax credit.
Authorized Signature
Title
Date
Printed Name
Phone Number
Email Address
FAX Number

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