Form Mdcta - Medical Device Credit Transfer Application - 2012

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2012

Form MDCTA

Massachusetts

Medical Device Credit

Department of

Transfer Application

Revenue

For calendar year 2012 or taxable year beginning

and ending

Medical device company name

Federal Identification or Social Security number

Mailing address

City/Town

State

Zip

Name of contact person

Telephone

E-mail address

1 Type of medical device company:

Corporation

Trust

Partnership

Sole proprietorship

LLC

Other

2 Medical device credit amount eligible for transfer (amount on line 4 of Form MDCC unused by the medical device

company/transferor). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

3 Certificate number issued by the Department of Revenue with respect to amount shown in line 2 above (from line 3

of Form MDCC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

4 Amount of medical device credit in line 2 above to be transferred with this application. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

5 Amount of financial assistance provided . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

If the financial assistance is other than in cash, please explain:

6 Date(s) financial assistance provided . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

7 Describe the Massachusetts use(s) to which the private financial assistance will be put:

Name of purchasing company

Federal Identification or Social Security number

Mailing address

City/Town

State

Zip

I declare under the pains and penalties of perjury that to the best of my knowledge, the information contained herein is accurate and complete.

Signature

Title of authortized representative

Date

Mail to: Massachusetts Department of Revenue, Audit Division, 200 Arlington Street, Room 4300, Chelsea, MA 02150, attn.: Medical Device Unit.