WISCONSIN DEPARTMENT OF COMMERCE
ANGEL TAX CREDIT REQUEST FORM
(All information in this form will be treated as confidential.)
|SECTION I. Individual Angel, Angel Entity Information |
|Individual Angel, Angel Entity | |
| |Telephone Number: |
|Name: | |
|Address line 1: |E-mail: |
|Address line 2: | |
|City, state, zip: |FEIN or SSN: |
|(Only for Angel Entity & if different from above) | |
|Entity Contact | |
| |Telephone Number: |
|Name: | |
|Address line 1: |E-mail: |
|Address line 2: | |
|City, state, zip: | |
|SECTION II. Qualified New Business Venture & Investment Information |
|Business | |
| |Telephone Number: |
|Name: | |
|Contact Name: |E-mail: |
|Address line 1: | |
|Address line 2: | |
|City, state, zip: | |
|SECTION III. Attachments |
|Please attach the following for this Investment: |
|Copy of the signed Investor/Subscription Agreement documenting the investment |
|Copy of the Investor’s wire transfer or check |
|Copy of the QNBV’s deposit slip or bank statement showing the deposit made |
|Accredited (Sophisticated) Investor Form |
|Cumulative Investment Allocation Worksheet listing all investors |
|SECTION IV. Qualified New Business Venture Attestation |
| |
|I hereby attest and certify that Angel Investor ______ invested $Cash invested(excludes debt and in-kind) and that these funds were available for use by the |
|certified business on Date Deposited and Available to the QNBV as cash equity investment after the certification date of Certification Date. |
| |
|The certified company is registered with the Wisconsin Department of Financial Institutions to do business in Wisconsin. () |
| |
|By signing this document, the company certifies that to the best of its knowledge and belief, the information being submitted to WEDC is true and correct. In |
|addition, the company agrees not to relocate more than 51% of its employees, total payroll or headquarters activities outside of Wisconsin for a minimum of 3 years |
|following the date of the investment that qualifies for tax credits under this request. Should the company relocate more than 51% of its employees, total payroll or |
|headquarters activities outside of Wisconsin within the 3 years following the date of investment the company agrees to pay a penalty as outlined below: |
| |
|Less or equal to 12 months following the investment the penalty shall be 100% of the credit claimed; or |
|More than 12 months and less than or equal to 24 months following the investment the penalty shall be 80% of the credit claimed; or |
|More than 24 months following the investment the penalty shall be 60% of the credit claimed. |
| |
| |
|__________________________________ ___________________________ |
|QNBV Treasurer Name Signature (digital signature acceptable) Date |
|(Only for Angel Entity) |
|ANGEL ENTITY INVESTOR DETAIL (Attach additional pages as necessary.) |
|Name |
|Name: (First, Middle Initial, Last) |Check if |Social Security Number |Investment Amount |
| |Qualified | | |
| |Investor | | |
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|Total Investment | |
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