Fillable Oregon State Tax Credit Application Form printable pdf download

Oregon State Tax Credit Application Form

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OREGON STATE UNIVERSITY

VENTURE DEVELOPMENT FUND

CONTRIBUTION AND TAX CREDIT APPLICATION FORM*

The applicant ("Applicant") identified below hereby makes a contribution to the OREGON STATE

UNIVERSITY Venture Development Fund and applies for a tax credit certificate. Applicant understands

that the University will consider this application as set forth in ORS 351.692 to 351.697, ORS 315.521, and

OAR 580-043-0085. Applicant further understands that the University will notify Applicant of the approval

or denial of this application. If this application is approved, the University will issue a tax credit certificate

specifying the amount of Applicant’s contribution. If the application is denied, the University will notify the

Applicant of the basis for the denial and that Applicant may submit a written request for a refund of the

contribution. A request for a refund of the contribution must be made within 90 days of the receipt of the

notice of denial. The Applicant also acknowledges that eligibility for a tax credit is subject to applicable law.

Applicant: ________________________________________________________________

Address: _________________________________________________________________

City: ______________________ State: ________________ Zip Code: _______________

Applicant Tax ID#: _________________________

Contact person (if other than above): ___________________________________________

Telephone: ________________________ E-mail: ________________________________

Amount of Contribution (if made in cash): $ _____________________

NOTE: The contribution must be made when the application is filed. If the application is denied, Applicant

will have an opportunity to request a refund of the contribution.

Signature of Applicant: _______________________________________ Date: _________

Signature of Applicant’s Representative: _________________________ Date: _________

__________________________________

______________________________

Name of Representative

Title

SUBMIT COMPLETED APPLICATION, INCLUDING CONTRIBUTION TO:

W. Glenn Ford

Vice President for Finance & Administration

Oregon State University

850 SW 35th Street

Corvallis, OR 97333

*This form must be signed by the Taxpayer and the Taxpayer’s Representative, if any.

Oregon State Tax Credit Application Form

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