Form N-318a - Statement Of Investment In A Qualified High Technology Business (Qhtb) - 2004

STATE OF HAWAII—DEPARTMENT OF TAXATION

STATEMENT OF INVESTMENT IN A

TAX

FORM

YEAR

N-318A

QUALIFIED HIGH TECHNOLOGY BUSINESS (QHTB)

2004

(Rev. 2004)

Or fiscal year beginning _________________, 2004, and ending __________________, 20___

ATTACH FORM N-318A TO FORM N-318, HIGH TECHNOLOGY BUSINESS INVESTMENT TAX CREDIT.

Name(s) as shown on the applicable form: Department of Taxation’s Form N-11, N-12, N-15, N-20, N-30, N-35, N-40, N-70NP,or F-1;

SSN or FEIN

or Department of Commerce and Consumer Affairs’ Form 314

INVESTMENT IN A QHTB. TO BE COMPLETED BY THE INVESTOR.

Part I

A.

If you are claiming a credit for an investment made in a QHTB, check box (1) and enter the name and Federal Employer Identification Number

(FEIN) of the QHTB for which you are claiming the credit. If you are claiming a credit that was distributed to you, check box (2) and enter the name

of the entity that issued you a Schedule K-1 reporting your share of the credit.

£

£

1.

2.

B.

If you checked Box 1 in Section A of Part I, check if the investment is at risk, as provided in Internal Revenue Code section 465.

£

£

Yes, investment is at risk

No, investment is not at risk

C.

If you received more or less than a proportionate share of the credit based upon your actual investment, please provide an explanation.

For example: Taxpayer claims a disproportionate share of the credit on Line 7 of Form N-318 (i.e. taxpayer claims the credit as reported on the

Schedule K-1 issued by the entity named in Section A of Part I and taxpayer’s share of the credit is disproportionate based on taxpayer’s actual

investment). In this example, the taxpayer is required to provide an explanation of the disproportionate share.

D.

If you claimed more than your proportionate share of the credit based upon your actual investment, please attach a list containing the following

information about each person:

1.

Name and address of other investors in the QHTB who allowed you to claim more than your proportionate share;

2.

The amount of the investment, the date the investment, and whether you borrowed cash or property to make the investment;

3.

A description of your investment (e.g., cash, intangible personal property, tangible personal property, real property);

4.

If the investment is property, briefly explain and attach documentation supporting the valuation of the property; and

5.

The consideration provided to other investors in the same QHTB that received less than their proportionate share of the credit (e.g., additional

shares of stock in the QHTB, units in the QHTB, promissory note, license).

DECLARATION

I hereby certify under the penalties of perjury that I have the authority to sign Part I of Form N-318A on behalf of the above named taxpayer. I declare, under the applicable

penalties set forth in sections 231-34, 231-35, and 231-36, HRS, and chapter 431, HRS, that the information reported in Part I of Form N-318A (including any accompanying

schedules or statements) has been examined by me and, to the best of my knowledge and belief, is true, correct, and complete and made in good faith, for the taxable year

stated, pursuant to the Hawaii Income Tax Law, Chapter 235, HRS; Hawaii Taxation of Banks or Other Financial Corporations, Chapter 241, HRS, or Hawaii Insurance Code,

Chapter 431, HRS.

Signature

Date

Print Name

Title

Part II

CERTIFICATION OF INVESTMENT IN A QHTB. TO BE COMPLETED BY THE QHTB.

If Box 2 of Section A, Part I, is checked, obtain a copy of the completed and signed Form N-318A from the entity named in Section A of Part I, attach the en-

tity’s Form N-318A to your Form N-318A, and write in the QHTB’s name area “N/A. See attached Form N-318A.”

QHTB’s NAME

FEIN

The undersigned QHTB hereby certifies:

A. The QHTB received $_____________________________ on ______________________________from the investor named above in exchange for

__________________________________(e.g., shares of stock in the QHTB, units in the QHTB, promissory note, license).

B. The QHTB has met the requirements of section 235-110.9(e), HRS, on the date the investment was received.

C. The amount received from the investor, as noted in Section A of Part II, is an "investment" as defined in section 235-1, HRS.

DECLARATION

The undersigned acknowledges that this completed and signed Part II of Form N-318A will be used by the above named investor as support for the investor’s claim for the credit

under section 235-110.9, HRS; section 241-4.8, HRS; or section 431:7-209, HRS. I hereby certify under the penalties of perjury that I have the authority to sign Part II of Form

N-318A on behalf of the QHTB. I declare, under the penalties of perjury and applicable penalties set forth in sections 231-34, 231-35, and 231-36, HRS, and chapter 431, HRS, that

the information reported in Part II of Form N-318A has been examined by me and, to the best of my knowledge and belief, is true, correct, and complete and made in good faith.

Signature

Date

Print Name

Title

FORM N-318A