Coin Cdfi Tax Credit Application Form Page 2

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LOS ANGELES
SACRAMENTO
300 SPRING STREET, SUITE 1100
300 CAPITOL MALL, SUITE 1600
LOS ANGELES, CA 90013
SACRAMENTO, CA 95814
PHONE: 916-492-3525
Yes/No
Percentage
Scoring Questions
Direct benefit to LMI households?
Direct benefit to rural areas?
Green investment?
Affordable rental housing?
Community based-residential programs?
Self-help housing?
Veteran housing?
Single-family owned housing?
Is the investor an insurance company?
Estimated number of temporary jobs created?
Estimated number of permanent jobs created?
Estimated number of jobs in high unemployment areas?
Is there any other statistical information that addresses the previous factors?
Note: If you have other metrics to evaluate the impact the investment, please describe these as part of your application.
ADDITIONAL COMMENTS OR CLARIFICATION ITEMS/MISCELLANEOUS NOTES
Tax Recapture/Early Withdrawal provision: If a “Qualified Investment” is withdrawn before the end of the 60th month and not re-deposited or
reinvested in another CDFI within 60 days, there shall be added to the “net tax” or “tax” (as defined in Revenue & Tax Code Section 17039,
Section 23036, or Section 28 of Article XIII of the California Constitution), for the taxable or income year in which the withdrawal occurs, the
entire amount of any credit previously allowed under Revenue & Tax Code Sections 17053.57 or 23657, and Section 12209. Additionally, under
Section 17053.57, the CDFI is required to notify COIN and the Franchise Tax Board; and under, 12209, the CDFI is required to notify COIN and
the Board of Equalization.
Amendments to Tax Credit Application Agreements: If an amendment is made to the original agreement, the CDFI
must notify COIN of the amendment.
STATEMENT OF ACKNOWLEDGEMENT
I hereby acknowledge and agree to the following terms and conditions:
i. The program may change due to statutory, regulatory, or judicial actions.
ii. Tax credit amounts allocated may be reduced if the terms and amounts of project sources and uses of funds are modified.
iii. Applicant and taxpayer shall continue to comply with all laws and regulations, including those prohibiting discrimination,
Revenue and Taxation and program requirements.
iv. Information submitted to COIN is subject to disclosure under the California Public Records Act, except as provided in
Code Sections 12209 (d) (3) (B), 17053.57 (c) (3) (B), 23657 (c) (3) (B), and any successor or other statutes.
v. The CDFI and taxpayer hold the Department and its employees harmless from liability deriving from the program or uses.
vi. The application will be evaluated according to COIN regulations.
vii. The CDFI will upon later request provide to COIN information needed to establish the benefits of the investment if a
certificate is issued.
viii. If any or all of the investment is withdrawn early or repaid, the portion withdrawn or repaid will be subject to the early
withdrawal provision and tax recapture.
i
Signature from COIN Certified CDFI
Print Name
Date
ii
Print Name
Signature from Investor/Taxpayer
Date
i
An original signature and date on the application form by a CDFI corporate officer attesting, under penalty of perjury under the laws of the
State of California, that all information provided by the CDFI is true and correct, and that the CDFI will notify COIN of changes causing
information in the application to become materially inaccurate or incomplete.
ii
An original signature and date on the application form by a natural person taxpayer, or an officer of a taxpayer that is not a natural person,
attesting, under penalty of perjury under the laws of the State of California, that all information provided by the taxpayer is true and correct, and
that the taxpayer will notify COIN of changes causing information in the application to become materially inaccurate or incomplete.
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