Form R-10609 - New Markets Tax Credit Application
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R-10609 (1/10)
Revenue Use Only
New Markets Tax Credit
Date Received
Application
PLEASE PRINT OR TYPE.
Investor/ Taxpayer Information
Name
Telephone number
Address
City
State
ZIP
Who is the contact person of the taxpayer applying for Louisiana New Markets Tax Credits
Telephone number
What type of entity is the taxpayer? If an LLC or partnership, list the members or partners and their percentages of ownership interest. Explain how the
New Markets Tax Credits should be allocated among them.
Qualified Equity Investment Information
1. Did the taxpayer make a qualified equity investment (QEI) within the meaning of section 45D of the Internal Revenue Code? If so, include documentation.
2. What is the name and address of the Community Development Entity (CDE) that issued the QEI?
3. What is the date and the amount of the QEI made into the CDE?
_____ / _____ / _____
$ _________________
mm/dd/yyyy
4. What is the date or the projected date _____ / _____ / _____ and the amount or the projected amount $ ______________ of the qualified low-income
mm/dd/yyyy
community investment (QLICI) made into the qualified active low-income business? If the QLICI has not yet been made, you will receive a valid allocation
of New Markets tax credits, but your New Markets Tax Credit Summary Sheet will not be issued until the qualified active low income community business
has been identified.
5. Did the QLICI investment exceed 7.5 million dollars?
Yes
No
■
■
6. Is this QLICI issued by a single qualified active low-income business which is designated as a target industry in R.S. 51:2453(2)(b)(i)?
Yes
No
■
■
7 . Did you apply to LED for certification of your target industry?
Yes
No
■
■
If no, do you intend to? If you answered yes to this question, include a certification letter from the
Louisiana Department of Economic Development (LED).
Yes
No
■
■
Name of Qualifying Active Low Income Business
Name
Address
City
State
ZIP
Purpose of the business that received the qualified low-income community investment from CDE listed in question above. If more than one business,
attach a schedule detailing the names, purposes and the amount of the QLICIs.
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