Form R-10609 Fillable New Markets Tax Credit Application
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

(: 1) Unchecked (: 1) Unchecked (: 2) Unchecked (: 2) Unchecked (Address) (Adjuted Purchase Price) (Allocated Percentage) (Allocated Percentage) (Allocated Percentage) (Allocated Percentage) (Allocated Percentage) (Allocated Percentage) (Amount of QEI) (City) (Contact Telephone Number) (Credit Allowance Date) (Credit Allowance Date) (Credit Allowance Date) (Credit Allowance Date) (Credit Allowance Date) (Credit Allowance Date) (Credit allowance) (Credit Amount) (Credit Amount) (Credit Amount) (Credit Amount) (Credit Amount) (Credit Amount) (Date) (Investor/Taxpayer Telephone Number) (Name of Investor or Investor Member/Partner) (Name of Investor or Investor Member/Partner) (Name) (Print Taxpayer Name) (Print Taxpayer Representative Name) (Purpose of Business) (State) (text) (text) (text) (text) (Who is the contact person) (ZIP) (ZIP) 1 Did the taxpayer make a qualified equity investment (QEI) within the meaning of section 45D of the Internal Revenue Code? If so include documentation 2 What is the name and address of the Community Development Entity (CDE) that issued the QEI? 3 What is the date and the amount of the QEI made into the CDE? $ 4 What is the date or the projected date and the amount or the projected amount $ of the qualified low income 5 Did the QLICI investment exceed 7 5 million dollars? Yes No 6 Is this QLICI issued by a single qualified active low income business which is designated as a target industry in R S 51:2453(2)(b)(i)? Yes No 7 Did you apply to LED for certification of your target industry? Yes No Address Adjusted Purchase price allowance date Amount of QLICI made on certain Amount of QLICI made on certain credit allowance Amount of QLICI on certain credit Application attach a schedule detailing the names purposes and the amount of the QLICIs Calculate the adjusted purchase price for all anniversary dates in accordance with Revenue Ruling 08 011 and the formula below and Calculation of Adjusted Purchase Price community investment (QLICI) made into the qualified active low income business? If the QLICI has not yet been made you will receive a valid allocation credit allowance date Credit Allowance Date Credit Amount Allocated Percentage Credit Allowance Date Credit Amount Allocated Percentage Credit Summary Sheet Use the New Markets Tax Credit Summary Sheet to claim and transfer the New Markets Tax Credit For additional Date (mm/dd/yyyy) date invested in Louisiana or to be invested Date Received has been identified I attest and affirm that the information detailed in this application is true and accurate to the best of my knowledge and I understand that upon the If no do you intend to? If you answered yes to this question include a certification letter from the indication of a misrepresentation of the facts therein I am subject to legal and tax consequences including a total recapture of credits granted as a result information regarding the New Markets credit contact the Special Programs Division at 225 219 2200 Investor/ Taxpayer Information Louisiana Department of Economic Development (LED) Yes No mm/dd/yyyy Name of In v est or or In v est or Member/P ar tner: Name of In v est or or In v est or Member/P ar tner: Name of Qualifying Active Low Income Business New Markets Tax Credit New Markets Tax Credits should be allocated among them Note: This application will be processed in the order received Once this application is processed you will receive a New Markets Tax of New Markets tax credits but your New Markets Tax Credit Summary Sheet will not be issued until the qualified active low income community business of the misrepresentation Print Taxpayer Name Print Taxpayer Representative Purpose of the business that received the qualified low income community investment from CDE listed in question above If more than one business Qualified Equity Investment Information R 10609 (1/10) Revenue Use Only State Submit this application to: NewMarketTax CreditApplication@la gov Taxpayer Representative or Taxpayer Signature Telephone number then place in table below If an LLC or partnership use a table for each member or partner What type of entity is the taxpayer? If an LLC or partnership list the members or partners and their percentages of ownership interest Explain how the Who is the contact person of the taxpayer applying for Louisiana New Markets Tax Credits