1.
Legal Name:
2.
Address:
3.
Contact Person:
3a.
Title:
Mr.
Mrs.
Miss
Ms.
Dr.
4.
Phone:
5.
Fax:
6.
Email:
7.
Employer Identification Number:(of company investing and
8.
Principal Place of Business:
9.
State of Incorporation:
Alabama
Alaska
Alberta
American Samoa
APO/FPO Address
APO/FPO Address
APO/FPO Address
Arizona
Arkansas
British Columbia
California
Colorado
Connecticut
Delaware
District of Columbia
Federation of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
New Hampshire
New Jersey
New Mexico
New York
Newfoundland
North Carolina
North Dakota
Northern Mariana Islands
Northwest Territories
Nova Scotia
Nunavut
Ohio
Oklahoma
Ontario
Oregon
Palau
Pennsylvania
Prince Edward Island
Puerto Rico
Quebec
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Yukon Territory
10.
Officer(s) Name:
Title:
Mr.
Mrs.
Miss
Ms.
Dr.
11.
Principal Owner(s) Name:
Principal Owner(s) Address:
Principal Ownership %:
12.
Check whether applicant:
is other than a public utility:
and operates in “for-profit” sector:
13.
Check applicant's organization status when reporting to the IRS:
C Corp:
S Corp:
Sole Proprietorship:
Partnership:
Limited Liability Company:
(list LLC “type”)
Other:
(list)
14.
Check whether applicant is “engaged in, or plans to engage in”:
15.
Check which range of “qualified” employees the applicant plans to hire in Maine above its “base level of employment” within the first two calendar years:
16.
The following questions (a-c) pertain to “retail operations” (i.e. the sale of consumer goods for household use to consumers who personally visit the applicant's business location to purchase the goods):
a.
Check whether applicant is engaged in retail operations:
b.
If no, go to #17. If yes, check whether 50% or more of the applicant's total annual revenues from Maine–based operations derived from sales taxable in Maine:
c.
If no, go to #17. If yes, check whether the applicant can demonstrate that any increased sales will not include sales tax revenues derived from transferring or shifting retail sales from other businesses in Maine:
17.
Check whether the applicant is investing at least $5 million in a taxable year in personal property and creating 100 new jobs within the ensuing two year period:
a.
If no, go to Section B. If yes, check whether the applicant has elected to take the Jobs and Investment Tax Credit:
1.
Check the zone where the applicant business will be established, or where its expansion is planned, including name of municipality, and tax map and lot number:
2.
Regarding the Physical Address listed above:
a.
Do all employees work in this location?
b.
If Yes, go to #3. If No, please list number of employees who work outside the PTDZ but use this as their base of operations:
3.
Check which of the following best describes the development project status:
4.
Check which of the following best describes the development project plans for existing Maine employees, positions or property:
5.
Provide a summary description of the applicant's planned development project which will constitute the “qualified business activity that is conducted within a PTDZ and is directly related to financial services, manufacturing or a targeted technology.”
6.
Provide a detailed development project plan, including descriptions of:
a.
the applicant, its products and/or services and history of operations;
b.
the market(s) and/or competitive environment in which the applicant operates or expects to operate; and
c.
the applicant's employment growth and investment plans for the next 5 years (including the year of application).
1.
Check whether the applicant has received funding from any of the following:
a.
b.
c.
2.
Provide a listing of the “sources and uses” of funds required to accomplish the development project:
3.
Check whether the project includes facilities to be constructed or modified, or other real estate investments:
If yes, provide details on the following:
4.
Check whether the project includes equipment to be purchased, or other personal property investments:
If yes, provide details on the following:
5.
Check whether the project includes employee training requirements, or other expenses associated with accomplishing the development project:
If yes, provide details on the following:
6.
Check whether the project includes hiring “qualified employees”:
If yes, provide the following information regarding hiring estimates:
7.
Using anticipated hiring data above, please provide the following information and calculations in order to estimate the potential tax benefit:
a.
# of Qualified Employees Each Year
b.
Qualified Employee Payroll Each Year
c.
Qualified Employee State Income Taxes Withheld (@4.5%)
d.
Annual Reimbursement to the Applicant (@80%)
e.
10–Year Reimbursement to the Applicant
1.
Preceding Calendar Year & Average Employment During the Base Period: List the total number of employees of the applicant business at the end of each quarter for the three calendar years immediately preceding the year of application, divided by four for the most recent year, and divided by twelve for all three years.
2.
Payroll and Income Tax Withholdings: List total payroll figures and income tax withholdings of the applicant for each of the three calendar years immediately preceding the year of application:
3.
Affiliated Business: List the name and location of any “affiliated business” based in Maine, including the total employment at year end, payroll figures and related income tax withholdings for each of the three calendar years immediately preceding the year of application:
An explanation demonstrating that the establishment or expansion of operations in a PTDZ would not occur within Maine “but for” the availability of the PTDZ benefits is required by law. If a letter addressing this issue was previously submitted to the DECD Commissioner, please reference the letter and date submitted.
1.
Check the public purpose (all that apply) that will be met through DECD's support of this PTDZ development project:
2.
Check whether applicant expects to receive more than $10,000 in tax reimbursements in any calendar year during the term of this initiative:
If yes, an annual report will be automatically sent to the business contact person each May with a filing deadline of August 1st.
3.
Check whether applicant is current on all taxes owed the State of Maine:
If no, please explain any and all deficiencies.
As an authorized official of the applicant business, I certify under the penalties of perjury that:
1.
The applicant is a for–profit business engaged, or to be engaged, in an eligible sector, i.e. financial services, manufacturing or a targeted technology, and seeking PTDZ tax benefits for only those qualified business activities that are certified as directly related to one or more of the eligible sectors;
2.
The applicant has added, or will add, at least one qualified employee above its base level of employment, who: will receive income derived from employment that, when calculated on a calendar year basis, exceeds the current annual per capita personal income in the county of employment; and will be offered participation in: a retirement program subject to the Employee Retirement Income Security Act of 1974, 29 U.S.C. §§1001-1461 and a group health insurance plan;
3.
The applicant will not seek PTDZ tax benefits for any existing property, employees or positions transferred by the applicant business, or any affiliated business, to a qualified business activity from a nonqualified activity;
4.
The applicant intends to undertake and complete the PTDZ development project as described in this application, has reviewed with all due diligence the PTDZ tax benefits provided under Maine law and understands how they will apply to development project plans, and assures that the development project would not occur within the State of Maine “but for” the availability of the PTDZ tax benefits; and
5.
This application is complete, and all information contained in it is true and correct, and current as of the date signed below, to the best of my knowledge.
Please make every attempt to utilize the space available for each question. If necessary, provide additional pages with the hard copy of the application you mail following electronic submittal. Be certain to include applicable reference numbers for any questions addressed.
In order to be considered for certification in calendar year 2007, please mail your completed application by December 1, 2007 to:
