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Angel Investor Tax Credit Sample Application
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Products Selected: Angel Investor Tax Credit Program

Contact Information
Salutation:
First Name:
Middle Initial:
Last Name:
Suffix:
Company:
Mailing Address:
Address Line 2:
City/Town:
State:
ZIP Code:
Telephone Number:
Email Address:

Investor Information
Investor Name:
(official, legal name without abbreviations)
Is the Investor's address and contact information the
same as the Contact's information?
Ownership Structure:
NAICS Number:

Qualified Investment Information		  
Date of Qualified Investment Amount Proposed Tax Credit
Qualified Investment Type:
Is this entity a related person (as defined in the Program rules) of the technology business?
   

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:
  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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).
  1. Laws banning or prohibiting discrimination or harassment in the workplace on the basis of gender, race, age, religion or handicapped status.
  2. Laws prohibiting or banning any form of forced, slave, or compulsory labor.
  3. Laws protecting workers who have reported the wrongdoing of their employers to governmental authorities, commonly referred to as "Whistleblower Laws".
  4. Securities or tax laws resulting in a finding of fraud or fraudulent conduct.
  5. Environmental laws.
  6. Laws banning the possession or sale of, or trafficking in, firearms or drugs.
  7. Laws banning anti-competitive dumping of goods.
  8. Anti-terrorist laws.
  9. Criminal laws involving commission of any felony or indictable offense under State, Federal or foreign law.
  10. Laws banning human rights abuses.
  11. Laws banning the trade of goods or services to enemies of the United States.
  12. 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:
Email Address:

Technology Business Organization Information
Applicant Organizational Name:
(official, legal name without abbreviations)
Is the Organization's address and contact information the
same as the Contact's information?
Website Address:
NAICS Number:
Nature of Business:
Please briefly describe any changes that have occurred in the information provided above between the time of the Qualified Investment, and the earlier of 6 months from the date of the Qualified Investment, or date of application, whichever comes first.

Technology Business Ownership Structure
The employee count should be as of date of investment
(Step 1 of 2)
  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.
The employee count should be as of date of application or 6 months after investment, whichever comes first
(Step 2 of 2)
  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
  • Provide one of the following agreements
    • Stock or Unit Purchase Agreement
    • Subscription Agreement
    • License Agreement
    • Rights To Use Technology Agreement
    • Marketing Rights Agreement
    • Warrants or Options Agreement
    • Membership Interest Agreement
    • Purchase, Production or Research Agreement
  • Stock or Unit Certificate
  • Evidence of cash transfer
    Please attach copy of cancelled check, or account statement showing that the cash was sent to the Company
  • Investor Certification Form


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. For the definition of a "New Jersey Emerging Technology Business", click here to view the program definitions.
  • Capitalization chart showing all owners and percentage ownership.
    The cap table should be dated immediately after date of investment and be signed by the Company CEO.
  • Copies of the technology business' Federal Form 941 and New Jersey WR-30 forms for 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 in US, for the period which includes the date of Qualified Investment. If the investment is made near year-end, you may alternatively provide New Jersey and Federal Froms W-3.
    Alternatively, documentation from the Company's 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 business or in the same controlled group as the business, in NJ and US, for period which includes the date of Qualified Investment.
    NOTE: These items will be viewable to the investor when attached to the application. You have the option of submitting these documents after completion of the online application
  • Technology Business CEO Certification Form