Keystone Opportunity Zone - Program Guidelines And Application - Pennsylvania Department Of Community And Economic Development Page 13
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1712.
Provide the information requested in the space provided below for the entities: all share holders,
partners, members, etc. of an S Corp, Partnership, LLC and all persons or businesses that will receive
pass through income from the business (attach additional sheets if necessary).
Name
Address
SSN/EIN
Phone
Ownership %
Sales Tax#
A.
B.
C.
D.
E.
F.
13. *Job Creation and Investment (This section must be completed. If not applicable enter zero.)
Number of Full Time jobs at KOZ site when you first moved to KOZ:
Number of Full Time jobs at KOZ site now:
Estimate of public & private capital (including cost or value of land) investment in KOZ site:
All applicants must be in full compliance with the KOZ and KOEZ Act, 73 P.S. §§ 820.101 – 820.1309
and with the Keystone Opportunity Zone Guidelines.
*I hereby certify that all the above information is true and correct:
Signature
Date
*
Print Name Title
First Date in Zone
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