LOUISIANA. Custom-Fit Opportunity. Enterprise Zone Program TAX CREDIT APPLICATION INSTRUCTIONS SECTION ONE (Application Page 4) Business Information Business Name: Company name of the business applicant as registered with the Louisiana Secretary of State Year Established: List the year the company was formed Description of Business: Explain what type of business the company is and explain its functionality Project s Physical Address: List the complete address of the site location where the project took place Business Mailing Address: Provide the address of the company s official location where written communication can be received Local Endorsement Resolution: Provide a copy of the resolution received from the local governing authority if local parish or city benefits were applied for and awarded SECTION TWO (Application Page 5) Initial Eligibility Question 1: Indicate if company, business or any affiliates are engaging in gaming activities Question 2: Indicate if another site location has closed or downsized as a result of the current project participating in the Enterprise Zone program Question 3: Indicate if there were previous EZ contracts at the current project s site location Question 4: Indicate if you have received a state-issued sale and use tax registration certificate SECTION THREE (Application Page 5) Corporate Structure As registered and recorded with the Louisiana Secretary of State s Office, please select your business s corporate structure SECTION FOUR (Application Page 5) Business Legal Structure Louisiana Department of Revenue Number: Provide SSN or LDR assigned number Louisiana Unemployment Number: Please provide unemployment ID number issued by the Louisiana Workforce Commission NAICS Code: Provide business North American Industry Classification System number assigned by the Louisiana Workforce Commission If your business is a LLC or S-Corp, Schedule 1 Provide a complete listing of all of the company s owners. The owner s legal name should be listed as registered with the Louisiana Department of Revenue, and their LDR number provided Schedule 2 List Affiliates of the applicant that made purchases for this project. Do not list construction contractors. The Affiliate s legal name should be listed as registered with the Louisiana Secretary of State, and their LDR number should be provided as issued by the Louisiana Department of Revenue Schedule 3 List Affiliates of the applicant that will report and claim the depreciable assets from this project on their federal tax return. The Affiliate s legal name should be listed as registered with the Louisiana Secretary of State, and their LDR number should be provided as issued by the Louisiana Department of Revenue 1
SECTION FIVE (Application Page 6) Project Information Project Type: Indicate if your project is a startup company, new construction, an addition to an existing structure or expansion to a current facility Project Beginning Date: Provide the start date of project where capital expenditures, delivery of equipment, hiring and construction commenced Project Ending Date: List the date in which you completed your project and/or finished making capital expenditures Project Description: Provide a brief explanation of your project details SECTION SIX (Application Page 6) Project Estimates Investment Costs: Building and Materials: Provide the amount spent on all building materials associated with this project Machinery and Equipment: Provide the cost of machinery and equipment leased, rented or purchased for this project Labor and Engineering: Provide the cost of wages paid for contract workers, construction workers, and/or to a general contractor for services rendered regarding this project Total Investment: Total estimated expenditures for the entire project, which includes the building, material, machinery, equipment, labor and engineering cost calculated previously Number of Jobs: Refer to application Annual Gross Payroll: Existing: Provide the total gross payroll of all existing employees In-State Transfer: Provide the total gross payroll of all employees that was transferred from another facility or site location from within the state Out-of-State: Provide the total gross payroll of all employees that was transferred from another facility or site location outside of the state Construction: Provide the gross payroll sum amount paid to construction workers and/or a general contractor for services rendered SECTION SEVEN (Application Page 6) Job Creation Estimates 1st Year: State the estimated number of permanent net new jobs that will be created in year one of your project and provide the sum of the annual gross payroll of the estimated permanent net new jobs for this year in the appropriate column 2nd Year: State the estimated number of net new jobs that will be created in year two of your project and provide the sum of the annual gross payroll of the estimated permanent net new jobs for this year in the appropriate column 3rd Year: State the estimated number of net new jobs that will be created in year three of your project and provide the sum of the annual gross payroll of the estimated permanent net new jobs for this year in the appropriate column 4th Year: State the estimated number of net new jobs that will be created in year four of your project and provide the sum of the annual gross payroll of the estimated permanent net new jobs for this year in the appropriate column 5th Year: State the estimated number of net new jobs that will be created in year five of your project and provide the sum of the annual gross payroll of the estimated permanent net new jobs for this year in the appropriate column Total: Provide the total sum of the estimated permanent net new jobs that will be created over the five year period 2
SECTION EIGHT (Application Page 7) Taxes Paid State Sales and Use Taxes Paid: Calculate the amount of state sales taxes paid on all building materials, machinery, equipment and other capital expenditure items related to this project Local Sales and Use Taxes Paid: Calculate the amount of local sales taxes paid on all building materials, machinery, equipment and other capital expenditure items related to this project SECTION NINE (Application Page 7) Fee Calculation Calculating your application fee If electing the Sales/Use Tax Rebate as your tax benefit: Add together your state and local sales tax estimated rebate from section eight Multiply the estimated number of permanent net new jobs reported in section seven by 2500 to calculate your estimated job tax credits If electing the Investment Tax Credit as your benefit: Take your total investment calculated in section six and subtract any items in that total that was exempted from taxes, if any, and multiple the difference, if applicable, by 1.5% to calculate your estimated investment tax credit SECTION TEN (Application Page 7) Application Fee Determining your application fee Add your estimated tax benefit (sales/use tax rebate or ITC) to the amount of estimated job tax credits and multiply the sum by 0.5 percent (0.005) to obtain your program application fee SECTION ELEVEN (Application Page 8) Project Contact Contact Type: Indicate if the person completing this application is a company representative or a hired third party. Contact Name: Name of the individual responsible for addressing and answering all questions pertaining to this application and EZ project Contact Person s Company Name: Name of company contact person Mailing Address: Preferred US Postal address of the contact where correspondence can be mailed Phone Number: Preferred contact telephone number associated with contact person listed Email Address: Preferred email address associated with contact name SECTION TWELVE (Application Page 8) Qualification Certification See application for details SECTION THIRTEEN (Application Page 9) Certification Certification section should be read, dated and signed by an authorized company official acknowledging the information provided in the application is true and correct
LOUISIANA. Custom-Fit Opportunity. Enterprise Zone Program Application File online at: http://fastlane.louisianaeconomicdevelopment.com FOR OFFICE USE ONLY DEPOSIT DATE DEPOSIT # CHECK # CHECK AMOUNT INITIALS CT/BG TAX CREDIT APPLICATION BUSINESS INFORMATION BUSINESS NAME YEAR ESTABLISHED IN LOUISIANA DESCRIPTION OF BUSINESS PROJECT S PHYSICAL ADDRESS CITY STATE ZIP CODE PHONE NUMBER EXT FAX NUMBER WEBSITE IS THE BUSINESS MAILING ADDRESS THE SAME AS THE PROJECT S PHYSICAL ADDRESS? YES NO IF NO, PLEASE PROVIDE MAILING ADDRESS BELOW. BUSINESS MAILING ADDRESS CITY STATE ZIP CODE PARISH DID YOU RECEIVE A LOCAL ENDORSEMENT RESOLUTION? YES NO IF YES, PLEASE ATTACH A COPY OF THE RESOLUTION. 4
INITIAL ELIGIBILITY The Board of Commerce and Industry has adopted rules prohibiting any gaming at the project site location and any gaming or gaming activity related to the operation of the business participating in the tax incentive program. 1. Has the applicant or any affiliates received, applied for or considered applying for a license to conduct gaming activities? If yes, attach a letter of explanation, including the name of the entity receiving or applying for the license, the relationship to the applicant if an affiliate, the location and the type of gaming activities. YES NO 2. Has another location within the state been closed or lost employment as a result of this project? If yes, attach a separate sheet listing the location(s) and number of employees lost at each location. YES NO 3. Has there been a previous Enterprise Zone contract at this location? YES NO 4. Do you have a Sales Tax Registration Certificate issued by Louisiana Department of Revenue (LDR) for this project? If yes, please attach a copy of your certificate. **An LDR issued tax certificate is required on all EZ projects. YES NO BUSINESS CORPORATE STRUCTURE Ownership Type: Corporation Limited Partnership Non-Profit Organization Individual or Sole Proprietorship S-Corporation General Partnership Limited Liability Company Foreign Corporation BUSINESS LEGAL STRUCTURE LOUISIANA DEPARTMENT OF REVENUE NO. LOUISIANA UNEMPLOYMENT NO. NAICS CODE SCHEDULE 1: Provide a complete listing of all of the company s owners. The owner s legal name should be listed as registered with the Louisiana Department of Revenue and their state tax identification provided. Attach additional sheets if more space is needed. LEGAL NAME LOUISIANA IDENTIFICATION NUMBER SCHEDULE 2: List Affiliates of the applicant that made purchases for this project. Do not list construction contractors. The Affiliate s legal name should be listed as registered with the Louisiana Secretary of State, and their state tax identification number should be provided as issued by the Louisiana Department of Revenue. Attach additional sheets if more space is needed. LEGAL NAME LOUISIANA IDENTIFICATION NUMBER 5
SCHEDULE 3: List Affiliates of the applicant that will report and claim the depreciable assets from this project on their federal tax returns. The Affiliate s legal name should be listed as registered with the Louisiana Secretary of State, and their state tax identification number should be provided as issued by the Louisiana Department of Revenue. Attach additional sheets if more space is needed. LEGAL NAME LOUISIANA IDENTIFICATION NUMBER PROJECT INFORMATION Project Type: Start-up/New Addition Expansion Other (please explain) Project beginning date: Project ending date: Provide a description of this project: PROJECT ESTIMATES Investments Costs Number of Jobs Annual Gross Payroll Building and Material Number of existing jobs at project site location Existing Jobs Machinery and Equipment Number of employees transferred from other in-state site locations and affiliates In-State Transfers Labor and Engineering Number of employees transferred from other out-of-state locations and affiliates Out-of-State Transfers Total Investment Number of construction jobs created as a result of this project Construction NEW JOB CREATION ESTIMATES In this section, please list the number of permanent net new jobs that will be created annually during the contract period. Annual Permanent Net New Jobs Gross Payroll for Permanent Net New Jobs 1st Year 2nd Year 3rd Year 4th Year 5th Year TOTAL 6
TAXES List the amount of State Sales/Use Taxes Paid List the amount of Local Sales/Use Taxes Paid (Total Investment minus Labor Cost 0.04 = State Taxes Paid) (Total Investment minus Labor Cost x Local Tax Rate = Local Sales Taxes Paid) ENTERPRISE ZONE FEE CALCULATION Estimated Sales/Use Tax Rebate Estimated Number of Permanent New Jobs Estimated State Sales/Use Tax Rebate Estimated Number of Permanent New Jobs Estimated Local Sales/Use Tax Rebate + Job Tax Credit Amount x Total Estimated Sales/Use Tax Rebate = Total Estimated Job Tax Credits = Estimated Investment Tax Credit APPLICATION FEE 500 (minimum) 15,000 (maximum) Total Estimated Sales Tax Rebate or Investment Tax Credit Total Estimated Job Tax Credits + Subtotal of Estimated Tax Benefits = Percentage Due (5/1000th) x 0.005 Application Fee = Please mail and make all checks payable to: Delivery/Courier Address: Louisiana Economic Development P.O. Box 94185 Baton Rouge, Louisiana 70804-9185 1051 N. Third Street Ste. 229 Baton Rouge, Louisiana 70802
PROJECT CONTACT Please provide the contact information of the person that can answer questions regarding this application or project. CONTACT TYPE: BUSINESS CONSULTANT (IF CONTACT IS A CONSULTANT, A DISCLOSURE AUTHORIZATION IS REQUIRED.) PREFIX FIRST NAME MI LAST NAME CONTACT PERSON S COMPANY NAME TITLE MAILING ADDRESS (IF DIFFERENT FROM BUSINESS MAILING ADDRESS) CITY STATE ZIP CODE PHONE NUMBER EXT EMAIL ADDRESS QUALIFICATION CERTIFICATION On behalf of the business submitting application and after making reasonable inquiry in order to fairly represent the intention of the business as of this date, for purposes of determining eligibility for the Enterprise Zone Program (EZ), the undersigned representative certifies that to the best of their knowledge: 1. The Enterprise Zone project for which application is made will result in at least the following number of net new jobs (permanent full-time jobs at the project site, as defined by EZ rules): Please check applicable box Existing Business Employees (nationwide including affiliates) Net New Jobs required for qualification (at the project site) 41 or greater 5 31 40 4 21 30 3 11 20 2 0 10 1 2. The business intends these net new jobs to be permanent jobs (jobs that currently have no anticipated end date falling within the EZ project period) 3. The applicant understands the jobs lost due to closure or downsizing of certain Louisiana sites of the business and affiliates, or relocation or downsizing of applicant headquarters (including parents, will be deducted in determining the number of net new jobs [as provided by EZ rules]). The applicant does/ does not currently anticipate such closure, relocation or downsizing (attach an explanation if applicable) DATE, 20 BUSINESS NAME SIGNATURE (AUTHORIZED COMPANY OFFICIAL) (Must be signed by owner, executive, senior level officer, project site manager or equivalent rank employee of the business.) PRINT (AUTHORIZED COMPANY OFFICIAL S NAME AND TITLE) 8
CERTIFICATION (Must have legal authority to sign this document) I hereby certify that the Enterprise Zone project identified in this document with the above referenced number and additional materials meets all of the requirements of R.S. 51:21, et seq. and applicable regulations. I hereby certify that the information provided in this document and additional materials is true and correct, and I am aware that my submission of any false information or omission of any pertinent information resulting in the false representation of a material fact may subject me to civil and/or criminal penalties for filing of false public records (R.S. 14:133) and/or forfeiture of any tax credits or rebates approved under this program. I understand that application and information submitted with it shall not be returnable to the applicant. Original Signature Printed Name and Title Date V2.10.13 9