Form Rev 81 1026 - High Unemployment County Application For Sales And Use Tax Deferral - Washington Department Of Revenue Page 2
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1
2
3Lessee Information
10. Percent of cogeneration energy produced and devoted to
internal use, if applicable:
1. Name of Lessee:
Manufacturing
%
2. Mailing Address:
Research and Development
%
3. Contact Person:
Other (please describe)
%
4. Phone Number:
5. Department of Revenue Tax Reporting Account
Number:
Yes
No
Total
100%
6. Do the lessee and lessor have 100%
same ownership?
Estimated Investment Project Costs
7. If the answer to question 6 is "Yes", please provide
Please only include costs that will be paid for by the applicant.
documentation to substantiate the relationship.
11. Structure:
8. If the answer to question 6 is "No", has the lessor agreed by
written contract to pass the economic benefit of the deferral
Date building permit will be issued
to the lessee?
Construction of new structure(s)
$
(Please attach a completed Lessee's Application, if applicable,
and a copy of the lease agreement reflecting the economic
Leasehold improvements paid for
benefit of the deferred tax is passed onto the lessee by any type
by applicant
$
of payment, credit, or other financial arrangement between the
Expansion or renovation to expand
lessor and qualified lessee.)
floor space or production capacity
$
Please have the lessee sign the following statement. Failure to
Construction of cogeneration facility
$
do so will prevent approval of the application.
Total Structure Costs
$
I agree to file an annual survey with the Department of Revenue
12. Machinery & Equipment:
th
by April 30
for eight years, beginning with the first calendar
Date equipment is to be acquired
year after the calendar year in which the investment project is
certified by the department as operationally complete.
Purchase Price
$
Name __________________________ Date
Lease contract price
$
Signature _______________________ Title
Fair market value of previously owned
machinery and equipment that is new to
the State of Washington
$
Apportionment of Structure
Total Machinery & Equipment Costs
$
If the facility is used partly for manufacturing and research and
development and partly for other purposes, the applicable tax
13. Total Costs
deferral shall be determined by apportioning the costs of
(Structure, Machinery, & Equipment)
$
construction. (Not all of these categories qualify for the
14. Estimated completion date
deferral.)
9. Percentage of facility devoted to:
Business Activity to be Conducted at this Facility
Accounting/Payroll
%
If additional space is needed to answer questions 15 and 16,
Administration
%
please attach additional pages.
Cafeteria
%
Common Areas
%
15. Describe the lessee’s manufacturing activity at this
facility:
Conference & Training Rooms
%
Customer Service
%
Manufacturing
%
Plant offices used by direct line
supervisors or other managers who
oversee the manufacturing process
%
16. Describe the lessee’s research and development activities
at this facility, if applicable:
Reception Area
%
Research & Development
%
Sales & Marketing
%
Warehouse
%
Other (please describe)
%
Total
100 %
REV 81 1026 (5/16/13)
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