Oregon State Tax Credit Application Form

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OREGON STATE UNIVERSITY
VENTURE DEVELOPMENT FUND
CONTRIBUTION AND TAX CREDIT APPLICATION FORM*
The applicant ("Applicant") identified below hereby makes a contribution to the OREGON STATE
UNIVERSITY Venture Development Fund and applies for a tax credit certificate. Applicant understands
that the University will consider this application as set forth in ORS 351.692 to 351.697, ORS 315.521, and
OAR 580-043-0085. Applicant further understands that the University will notify Applicant of the approval
or denial of this application. If this application is approved, the University will issue a tax credit certificate
specifying the amount of Applicant’s contribution. If the application is denied, the University will notify the
Applicant of the basis for the denial and that Applicant may submit a written request for a refund of the
contribution. A request for a refund of the contribution must be made within 90 days of the receipt of the
notice of denial. The Applicant also acknowledges that eligibility for a tax credit is subject to applicable law.
Applicant: ________________________________________________________________
Address: _________________________________________________________________
City: ______________________ State: ________________ Zip Code: _______________
Applicant Tax ID#: _________________________
Contact person (if other than above): ___________________________________________
Telephone: ________________________ E-mail: ________________________________
Amount of Contribution (if made in cash): $ _____________________
NOTE: The contribution must be made when the application is filed. If the application is denied, Applicant
will have an opportunity to request a refund of the contribution.
Signature of Applicant: _______________________________________ Date: _________
Signature of Applicant’s Representative: _________________________ Date: _________
__________________________________
______________________________
Name of Representative
Title
SUBMIT COMPLETED APPLICATION, INCLUDING CONTRIBUTION TO:
W. Glenn Ford
Vice President for Finance & Administration
Oregon State University
850 SW 35th Street
Corvallis, OR 97333
*This form must be signed by the Taxpayer and the Taxpayer’s Representative, if any.

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