Form BA-405 Expired VEPC Credit: Annual Activity Report

1a Period covered (Months & Year) 1b Number of full time VT Employees 2 Report average annual full time VT employment for this tax year (average of the four quarters above) 2 3a During the first six years after the beginning of the EATI authorization what was the highest average 3b In which tax year did this occur? 3b 4 What was the lowest number of full time employees in Vermont for any 120 consecutive day period annual full time Vermont employment using the same calculation method as above? 3a Form BA 405 must be filed with the Vermont Business Corporate or Individual Income Tax Return for 6 years following the end of the EATI authorization period For example if the Vermont Economic Progress Council (VEPC) authorized an award from January 1 2000 through December 31 2004 Form BA 405 must be filed with all tax returns from 2005 through 2010 Send a duplicate of this form to: Vermont Economic Progress Council National Life Building Drawer 20 Montpelier VT 05620 0501 that ended during this tax year? 4 133 State Street (802) 828 5723 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter BA 405 Beginning Contact Person Name Title Phone Number Fax Number E mail Economic Advancement Tax Incentives Employment Report for Expired Authorizations Ending Entity Name Entity Officer Signature Title Date Entity primary 6 digit North American Industrial Classification System (NAICS) No Entity Tax Year M M Y Y Y Y Federal ID Number Form BA 405 Full Time Employment Levels in Vermont If Line 4 is less than 75% of Line 3a you must notify the Vermont Economic Progress Council within 60 days of the 120 consecutive day period and report the recapture on the Vermont Income Tax Return for the tax year in which the 120 consecutive day period occurred Refer to 32 V S A 5930h for details Location of Project (Street Address or Other Description) Mailing Address City or Town State Zip Code Montpelier VT 05633 1401 Web site: http://tax vermont gov PRINT in BLUE or BLACK INK Printed Name Phone E mail Report the average number of full time employees in Vermont for each quarter of the tax year For purposes of this form a full time employee is defined as an employee who works no less than 37 hours each week Rev 10/11 Signature Under penalties of perjury I declare this report and all documents attached in support of this report are true correct and complete to the best of my knowledge and belief VERMONT VT DEPARTMENT OF TAXES