*********************************************
Angel Investor Tax Credit Program Sample Application
*********************************************
|
|
|
Products Selected:
|
Angel Investor Tax
Credit Program
|
Contact Information
|
Salutation:
|
|
First Name:
|
|
Middle Initial:
|
|
Last Name:
|
|
Suffix:
|
|
Title:
|
|
Company:
|
|
Mailing Address:
|
|
Address Line 2:
|
|
City/Town:
|
|
State:
|
|
ZIP Code:
|
|
Telephone Number:
|
|
Fax Number:
|
|
Email Address:
|
|
Applicant Organization
Information
|
Applicant
Organizational Name:
(official, legal
name without abbreviations)
|
|
Federal Employer's
I.D. No. (FEIN):
|
|
Doing Business As
Name:
|
|
Holding Company
Name:
|
|
Authorized
Representative:
|
|
Title:
|
|
Is the
Organization's address the
same as the Contact's address?
|
|
Street Address:
|
|
Address Line 2:
|
|
City/Town:
|
|
State:
|
|
ZIP Code:
|
|
County:
|
|
Telephone Number:
|
|
Website Address:
|
|
Number of
Employees:
|
|
NAICS Number:
|
|
Nature of
Business:
|
Year Established:
|
|
State of
Incorporation/Formation:
|
|
Has the applicant,
or any related parties, previously received EDA assistance?
|
|
Qualified Investment
|
|
Date of Qualified
Investment
Disbursement
|
Amount
|
Proposed Tax Credit
|
|
|
|
|
Please provide a
brief description of the Qualified Investment provided to the technology
business and description of documentation of the Qualified Investment
(i.e., stock agreement; subscription agreements; license agreement;
agreement providing rights to use technology; marketing rights agreement;
warrants; options or similar interests; purchase, production or research
agreements).
|
|
Investor Ownership
Structure
|
Ownership
Structure:
|
|
Is this entity a related
person (as defined in the Program rules) of the technology business?
|
|
Is this entity :
Privately held? Publically traded?
|
|
What is the
Investor's tax year end?
|
|
|
|
Additional Background
Information
Businesses and individuals applying for eligibility for
NJEDA programs are subject to the Authority's Disqualification/Debarment
Regulations (the "Regulations"), which are set forth in N.J.A.C.
19:30-2.1, et seq. Applicants are required to answer the following
background questions pertaining to the commission of certain actions that
can lead to debarment or disqualification from eligibility under the
Regulations.
All capitalized terms used in this Questionnaire, except
those defined elsewhere herein, shall be defined at the bottom of this
form.
|
1. Commission of a
criminal offense as an incident to obtaining or attempting to obtain a
public or private contract, or subcontract thereunder, or in the
performance of such contract or subcontract.
|
|
2. Violation of
the Federal Organized Crime Control Act of 1970, or commission of
embezzlement, theft, forgery, bribery, falsification or destruction of
records, perjury, false swearing, receiving stolen property, obstruction
of justice, or any other offense indicating a lack of business integrity
or honesty.
|
|
3. Violation of
the Federal or State antitrust statutes, or of the Federal Anti-Kickback
Act (18 U.S.C.874).
|
|
4. Violation of
any law governing the conduct of elections of the Federal Government,
State of New Jersey or of its political subdivision.
|
|
5. Violation of
the "Law Against Discrimination" (P.L. 1945, c169, N.J.S.A
10:5-1 et seq., as supplemented by P.L. 1975, c127), or of the act
banning discrimination in public works employment (N.J.S.A 10:2-1 et
seq.) or of the act prohibiting discrimination by industries engaged
in defense work in the employment of persons therein (P.L. 1942, c114, N.J.S.A
10:10, et seq.).
|
|
6. To the best of
your knowledge after reasonable inquiry, violation of any laws governing
hours of labor, minimum wage standards, prevailing wage standards,
discrimination in wages, or child labor.
|
|
7. To the best of
your knowledge, after reasonable inquiry, violation of any law governing
the conduct of occupations or professions of regulated industries.
|
|
8. Debarment by
any department, agency, or instrumentality of the State or Federal
government.
|
|
9. Violation of
any of the following prohibitions on vendor activities representing a
conflict of interest, or failure to report a solicitation as set forth
below:
- No person shall pay,
offer or agree to pay, either directly or indirectly, any fee,
commission, compensation, gift, gratuity, or other thing of value of
any kind to any Authority officer or employee or special Authority
officer of employee, as defined by N.J.S.A 52:13D-13(b) and
(e), with which such person transacts or offers or proposes to
transact business, or to any member of the immediate family as
defined by N.J.S.A 52:13D-13i, of any such officer or
employee, or partnership, firm or corporation with which they are
employed, or associated, or in which such officer or employee has an
interest within the meaning of N.J.S.A 52:13D-13g.
- The solicitation of any
fee, commission, compensation, gift, gratuity or other thing of
value by any Authority officer or employee or special Authority
officer or employee from any person shall be reported in writing by
the person to the Attorney General and the Executive Commission on
Ethical Standard.
- No person may, directly
or indirectly, undertake any private business, commercial or
entrepreneurial relationship with, whether or not pursuant to
employment, contract or other agreement, express or implied, or sell
any interest in such person to, any Authority officer or employee or
special Authority officer or employee having any duties or
responsibilities in connection with the purchase, acquisition or
sale of any property or services by or to the Authority, or with any
person, firm or entity with which he or she is employed or
associated or in which he or she has an interest within the meaning
of N.J.S.A 52:13D-13g. Any relationships subject to this
subsection shall be reported in writing to the Executive Commission
on Ethical Standards, which may grant a waiver of this restriction
upon application of the Authority officer or employee or special
Authority officer or employee upon a finding that the present or
proposed relationship does not present the potential, actuality or
appearance of a conflict of interest.
- No person shall
influence, or attempt to influence or cause to be influenced, any
Authority officer or employee or special Authority officer or
employee in his or her capacity in any manner which might tend to
impair the objectivity or independence of judgment of the officer or
employee.
- No person shall cause or
influence, or attempt to cause or influence, any Authority officer
or employee or special Authority officer or employee to use, or
attempt to use, his or her official position to secure unwarranted
privileges or advantages for the person or any other person.
|
10. Has any member
of the Controlled Group been found guilty, liable or responsible for the
violation in any Legal Proceedings of any State, Federal or foreign law
that may bear upon a lack of responsibility or moral integrity, or that
may provide other compelling reasons for disqualification. (Your
responses to the foregoing question should include, but not be limited
to, the violation of the following laws, without regard to whether any
monetary award, damages, verdict, assessment or penalty has been made
against any member of the Controlled Group, except that any violation of
any environmental law in category (v) below need not be reported where
the monetary award damages, etc. amounted to less than $1 million).
- Laws banning or
prohibiting discrimination or harassment in the workplace on the
basis of gender, race, age, religion or handicapped status.
- Laws prohibiting or
banning any form of forced, slave, or compulsory labor.
- Laws protecting workers
who have reported the wrongdoing of their employers to governmental
authorities, commonly referred to as "Whistleblower Laws".
- Securities or tax laws
resulting in a finding of fraud or fraudulent conduct.
- Environmental laws.
- Laws banning the
possession or sale of, or trafficking in, firearms or drugs.
- Laws banning
anti-competitive dumping of goods.
- Anti-terrorist laws.
- Criminal laws involving
commission of any felony or indictable offense under State, Federal
or foreign law.
- Laws banning human rights
abuses.
- Laws banning the trade of
goods or services to enemies of the United States.
- The New Jersey Conflicts
of Interest Law, N.J.S.A 52:13D-1, et seq.
|
11. To the best of
your knowledge, after reasonable inquiry, is any member of the Controlled
Group a party to pending Legal Proceedings wherein any of the offenses or
violations described in questions 1-10 above are alleged or asserted
against such entity or person?
|
|
If the answer to any of the foregoing questions is
affirmative, you must provide the following information as an attachment
to the application: (i) the case and court in which such matters were
tried or are pending; (ii) the charges or claims adjudicated or alleged;
and (iii) a brief explanation of the circumstances giving rise to such
matters. Also, for affirmative answers to question 1-10, copies of the
final judgments, consent orders or administrative findings, as the case
may be, that were entered or made in such matters must be attached.
The terms set forth below shall be defined as follows:
"Affiliates" means persons having an overt or
covert relationship such that any one of them directly or indirectly
controls or has the power to control another.
"Legal Proceedings" means any State, Federal or
foreign civil, criminal or administrative proceeding in a court or
administrative tribunal in the United States, any territories thereof or
foreign jurisdiction.
The Authority reserves the right to require additional
clarifying or explanatory information from the
applicant("Applicant") regarding the answers given. If, at any
time prior to board action on this application, or, at any time between
the date of such action and the execution of a grant agreement with the
Authority, the Applicant should become aware of any facts that materially
alter or change such answers, or render any of them incomplete, the
Applicant shall have a duty to immediately report such facts to the
Authority in writing.
|
Certification of
Application
|
I, THE UNDERSIGNED, BEING DULY SWORN UPON MY OATH SAY:
1. I affirm, represent, and warrant that the information
contained in this application and in all attachments submitted herewith
is to the best of my knowledge true and complete.
2. I understand that if such information is willfully false,
I am subject to criminal prosecution under N.J.S.A. 2C:28-2 and civil
action by the EDA and the Division of Taxation which may at its option
terminate its financial assistance.
3. I authorize the New Jersey Department of Law and Public
Safety to verify any answer(s) contained herein through a search of its
records, or records to which it has access, and to release the results of
said research to the EDA.
4. I authorize the EDA to provide information submitted to
it by or on behalf of the applicant to the Division of Taxation or other
State agency which might need to be involved in the approval of the
requested tax credit.
|
[ ] I am Authorized Signer and I accept the terms and conditions.
|
Technology Business
Contact Information
|
Salutation:
|
|
First Name:
|
|
Middle Initial:
|
|
Last Name:
|
|
Suffix:
|
|
Title:
|
|
Company:
|
|
Mailing Address:
|
|
Address Line 2:
|
|
City/Town:
|
|
State:
|
|
ZIP Code:
|
|
Telephone
Number:
|
|
Fax Number:
|
|
Email Address:
|
|
Technology Business
Organization Information
|
Applicant
Organizational Name:
(official, legal
name without abbreviations)
|
|
Doing Business
As Name:
|
|
Holding Company
Name:
|
|
Authorized
Representative
(person able to legally bind the Applicant):
|
|
Title:
|
|
Is the
Organization's address the
same as the Contact's address?
|
|
County:
|
|
Telephone
Number:
|
|
Website Address:
|
|
NAICS Number:
|
|
Nature of Business:
|
|
Year
Established:
|
|
Total number of
years in NJ:
|
|
State of
Incorporation/Formation:
|
|
Has the
applicant, or any related parties, previously received EDA assistance?
|
|
Technology Business
Ownership Structure
|
|
|
|
Column A
Employees Filling a Position in New Jersey 1,2
|
Column B
Employees Based Outside of New Jersey
|
Column C
Total of Columns
A & B
|
Applicant
|
|
|
|
Entities other
than the investor with control over the technology business (even if inactive)
|
|
|
|
Entities in
the same controlled group as the technology business (even if
inactive)
|
|
|
|
Subsidiaries
not included above (even if inactive)
|
|
|
|
TOTALS:
|
|
|
|
1 Filling a
position in New Jersey - means a full-time employee whose primary
office is in New Jersey and who spends at least 80 percent of his or
her time in New Jersey, or who spends any other period of time
generally accepted by custom or practice as full-time employment in New
Jersey, as determined by the Authority.
|
2 Full-time
employee" means a person employed by a New Jersey emerging
technology business on a permanent or indefinite basis for
consideration for at least 35 hours a week, or who renders any other
standard of service generally accepted by custom or practice, as
determined by the Authority, as full-time employment and whose wages
are subject to withholding as provided in the New Jersey Gross Income
Tax Act, N.J.S.A. 54A:1-1 et seq.; or who is a partner of a New
Jersey emerging technology business who works for the partnership for
at least 35 hours a week, or who renders any other standard of
service generally accepted by custom or practice as full-time
employment, and whose distributive share of income, gain, loss, or
deduction, or whose guaranteed payments, or any combination thereof,
is subject to the payment of estimated taxes, as provided in the New
Jersey Gross Income Tax Act, N.J.S.A. 54A:1-1 et seq. or an employee
who is a resident of another state who works in New Jersey but whose
income or distributive share of income, gain, loss or deduction, or
guaranteed payments or any combination thereof is not subject to the
New Jersey Gross Income Tax Act, N.J.S.A. 54A:1-1 et seq., by virtue
of a reciprocity agreement between New Jersey and the state in which
the employee resides; or who is employed under a formal written
agreement with an institution of higher education whereby the
institution's students are employed by the New Jersey emerging
technology business on a permanent basis within a single position and
in compliance with all other requirements of "full-time
employee." "Full-time employee" shall not include any
person who works as an independent contractor or on a consulting
basis for the New Jersey emerging technology business; or any person
who works as an intern, as a temporary employee, or in a temporary
position.
|
3 Column A
TOTAL must be at least 75% of Column C to qualify for this program.
|
4 Column C
TOTAL cannot exceed 224 to qualify for this program.
|
Investor
Required Attachments
- Evidence of Qualified Investment
- Stock purchase agreement, Subscription agreement, or Options/Warrant exercise agreement
- Stock certificate
- Proof of cash transfer (Canceled check or Account statement)
- New Jersey Business Registration
- All investor entities (both NJ and out- of-state), including Corporations, Partnerships and LLC's, must register as doing business in the State of NJ. Please click here and complete online questions or questionnaire for both Step 1 ($125) and Step 2. Please print and attach the completion confirmation page for each step. To assist in completing Part 2, please use the 10 Digit ID established in Part 1.
- New Jersey investors that have already registered DO NOT need to reregister again.
- Individuals and Trusts DO NOT need to register.
- Tax Clearance Application
- All New Jersey and out- of-state investor entities, including Corporations, Partnerships and LLC's need to file a Tax Clearance Application with New Jersey Division of Taxation.
- Download Application for Tax Clearance
- Instructions: Please only complete the information above the dotted line on page 1 of the application and sign and date it at the bottom. Additionally please fill out the second page if applicable. Please send Application and $75 processing fee to NJEDA Attn: Bonds & Incentives, 36 West State Street, P.O. Box 990, Trenton, NJ 08625
- Individuals and Trusts DO NOT need to file.
- Investor Certification
|
Technology Business
Required Attachments
- Narrative description as fully and precisely as possible how the business qualifies as a "New Jersey Emerging Technology Business", including product or service and market focus. Please attach this as a separate document. This should not be a business plan, a company overview or a 10K. Be sure to describe the business and the nature of the operations within New Jersey.
- Copies of the technology business' Federal and New Jersey W-3 forms for technology business and all entities other than the investor with control over the business or in the same controlled group as the business, in NJ and in US, for period which includes the date of the Qualified Investment; or Alternatively documentation from Professional Employment Organization (PEO) summarizing W-2 Forms issued on behalf of the technology business, and all entities other than the investor with control over the business or in the same controlled group as the business, in NJ and US, for period which includes the date of the Qualified Investment. NOTE: These items will be viewable to the investor when attached to the application. You have the option of submitting these after completion of the online application.
- Evidence of the Qualified Investment provided to the technology business including, but not limited to stock agreement; subscription agreements; license agreement; agreement providing rights to use technology; marketing rights agreement; warrants; options or similar interests; purchase, production or research agreements.
- Technology Business CEO Certification
|
|
|
|
|
|