Form R-10608 - New Markets Jobs Premium Tax Credit
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1R-10608 (7/13)
New Markets Jobs Premium Tax Credit
Qualified Equity Investment (QEI) Certification Application
PLEASE PRINT OR TYPE.
Community Development Entity (CDE) Information
CDE Name
CDE EIN
Mailing Address
City
State
ZIP
Telephone Number
Fax
Email
(
)
Contact Person
QEI Information
Purchaser or Taxpayer Name
Mailing Address
City
State
ZIP
Name of entity or subsidiary that will claim, allocate or transfer credits if different from above.
Mailing Address
City
State
ZIP
Telephone Number
Fax
Email
(
)
Contact Person
Amount of QEI
Date or Projected Date of QEI
(mm/dd/yyyy)
Qualified Active Low-Income Community Business (QALICB) Information
QALICB Name
Amount of Qualified Low-income Community Investment (QLICI)
Date of QLICI
(mm/dd/yyyy)
Mailing Address
City
State
ZIP
Telephone Number
Fax
Email
(
)
Contact Person
Projected number of positions that will result from the investment
Projected Salary Ranges
Number of Full-Time and/or Part-Time Positions
Required Attachments:
1. A certification of the qualified community development entity as provided in Section 45D of the Internal Revenue Code.
2. A certification that Louisiana is included in the service area of the applicant.
3. A certified allocation agreement executed by the applicant or its controlling entity and the CDFI fund.
4. A certificate executed by an executive officer of the applicant attesting that the allocation agreement remains in effect
and has not otherwise been revoked or cancelled by the Community Development Financial Institution and that the
applicant has remaining unissued federal allocation at least in the amount of QEI authority for which it has applied.
5. A description of the proposed amount, structure and purchaser of the qualified equity investment.
6. A check made out to the Louisiana Department of Revenue in the amount of $500,000.00.
7. Attach additional sheets if more than one QALICB.
CDE Contact Person
CDE Contact Person Signature
Printed Name
Title
Date
(mm/dd/yyyy)
Submit this application to: NewMarketTax.CreditApplication@la.gov
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Parent category: Financial