Form It-Qbr - Qualified Business Registration Form
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IT-QBR (REV. 5/12)
Page 1
QUALIFIED BUSINESS REGISTRATION FORM
This form must be submitted by a Qualified Business to register with the Department
every 12 months as required by O.C.G.A. § 48-7-40.30 (Qualified Investor Tax Credit).
Name of the Qualified Business
FEI Number
Street Address
Type of Business
Partnership/LLC
C Corporation
S Corporation
City, State and ZIP Code + Four
Date
Contact Person
Telephone Number of Contact Person
Street Address of Headquarters of Qualified Business (if different) City, State and ZIP Code of Headquarters of Qualified Business *
Part 1.
1. Describe the type(s) of business in which the Qualified Business is primarily engaged?
_______________________________________________________________
________________
2. When was the Qualified Business organized?**
________________
3. Number of Georgia employees of the Qualified Business? ***
________________
4. Number of jobs created during the last 12 months
________________
5. Average wage for jobs created during the last 12 months
* If a qualified business is not headquartered in Georgia, then it does not satisfy the
statutory definition of a qualified business under O.C.G.A § 48-7-40.30 and its
registration will be denied.
** If a qualified business has been organized for more than 3 years, then it does not
satisfy the statutory definition of a qualified business under O.C.G.A. § 48-7-40.30 and its
registration as a qualified business will be denied.
***If a qualified business employs more than 20 people in Georgia, then it does not
satisfy the statutory definition of a qualified business under O.C.G.A. § 48-7-40.30 and its
registration will be denied.
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