Form Eotc-A - Application For West Virginia Economic Opportunity Tax Credit For Investments Placed In Service On Of After January 1, 2003
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5EOTC-A
Application for West Virginia Economic Opportunity Tax Credit
For Investments Placed in Service On of After January 1, 2003
Rev. 12/11
BUSINESS NAME
IDENTIFICATION NUMBER
TAX YEAR
TO
MM
DD
YYYY
MM
DD
YYYY
NAME OF TAXPAYER
PERSON TO CONTACT CONCERNING THIS RETURN
ADDRESS
PREPARER’S EIN
CITY, STATE, ZIP
DAYTIME TELEPHONE
Application is hereby made to the Tax Commissioner of West Virginia for allowance of Economic Opportunity Tax Credit with
respect to qualified investment property placed in service or use during Applicant’s tax year, as indicated above, and the
new jobs created by the Applicant that are directly attributable to the qualified investment property that are filled by persons
who are domiciled in this State.
1. a.
Application Status (Check only one):
a.)
One Year Investment, One Taxpayer
Multiple Year Investment, One Taxpayer – Must receive Certification from Tax Commissioner
b.)
Note: An application must be filed for each year in which investment for purpose of the Economic Opportunity Tax
Credit is placed in service or use. Additionally, the application must be approved by the State Tax Commissioner
before any credit may be claimed.
b.
Type of Credit:
Regular Credit
Headquarters Relocation
Small Business
Other (See instructions)
Specified High Technology Manufacturer
2. a.
Investment
Total Investment
Qualified Investment
Year-1 (ending)
Amount $
$
MM
DD
YYYY
Year-2 (ending)
Amount $
$
MM
DD
YYYY
Year-3 (ending)
Amount $
$
MM
DD
YYYY
b.
Location(s) of Investment in West Virginia
___________________________________________________
c.
General Description of Qualified Investment:
EOTC-1
Page 1 of 2
Rev. 12/11
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