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

Form 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: Starting in 2005, the Form QBA doesn’t 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 “Qualified Business” in instructions, Va. Code § 58.1-339.4, or 23 VAC 10-110-225

et seq. Attach a separate page if additional space is needed.

1. TYPE (check one):

C Corporation

S Corporation

Partnership

Limited Liability Company (LLC)

2. Was your business created to commercialize research

developed at or in partnership with an institution of higher

education?

Yes

If yes, what is the name of the institution?

3. Is its principal office or facility in Virginia?

Yes

No If No, STOP; the business does not qualify

4. 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

5. 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?

6. 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

loan institutions)?

Yes If Yes, STOP; the business does not qualify

7. 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).

Issuance Information

8. Describe the type of instrument the business entity is planning to issue for 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

E-mail Address

FAX Number

Va. Dept. of Taxation

QBA W

12/11

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

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