DEP Form # 62-788.900(1) - Florida Administrative Register
Approved
Denied
(DEO Use Only)
[pic]
Florida Space Business Incentive: Transfer Statement
Pursuant to the provisions of section 220.194, Florida Statutes, and as incorporated by reference in Rule 73A-5.001(1)(c), Florida Administrative Code, in order to perfect a transfer of Net Operating Loss Tax Credits, a Certified Applicant must complete this form. A separate form must be completed for each Transferee.
Through the submission of this Transfer Statement, it is the intent of the undersigned Certified Applicant to transfer its Net Operating Loss Tax Credits, as authorized by Department of Economic Opportunity, to the below listed Transferee, and hereby provide the following information:
SECTION I – APPLICANT INFORMATION
Certified Applicant Name: ___________________________________________
Application for Approval number: __________ Application for Certification number: __________
Transferee’s Name: _________________________________________________
Transferee’s Physical address: (no E-Mail or PO Box addresses)
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Transferee’s Federal Employment Identification Number (FEID): __ __ __ __ __ __ __ __ __
Transferee’s tax period: ____________________________________
Total amount of Net Operating Loss Tax Credits Certified: _________________________
Total amount of Net Operating Loss Tax Credits being transferred: ______________________
Effective date of the transfer: _______________________
I request that all correspondence related to this Transfer Statement be sent to the following point of contact by one of the following methods:
Point of Contact name: ______________________________________________________
E-mail address: ____________________________________________________________________
Postal address:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
SECTION II – Applicant Certification
The above named Certified Applicant meets the criteria required to transfer its Florida net operating loss, that would otherwise be available to be taken by it, as provided under subsection 220.194(4), Florida Statutes.
Yes No
The above named Transferee meets the criteria required to accept the transfer as provided under section 220.194(4), Florida Statutes.
Yes No
The undersigned Certified Applicant certifies that (s)he has read and understands the requirements of both section 220.194, Florida Statutes, and Chapter 73A-5, Florida Administrative Code, and that all information and documentation submitted in conjunction with this Transfer Statement are true and correct. The Certified Applicant further certifies that (s)he has an eligible spaceflight business and that the Net Operating Loss Tax Credit the Certified Applicant is seeking to transfer is or will be for an eligible spaceflight project, or projects.
_____________________________________ __________________________
Signature of Applicant Date
_____________________________________ ______________________
Print Name Print Title
____________________________________________________
Print Company Name (if applicable)
Send Completed Form to:
Department of Economic Opportunity
Division of Strategic Business Development
107 E. Madison Street, MSC 80
Caldwell Building
Tallahassee, FL 32399
ATTN: Spaceflight Business Tax Incentive
-----------------------
Florida Department of Economic Opportunity
DEO/SBD194(3)
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