Application Instructions


Applicant Information
Investor Details
Investor Name:  
   
Affiliation to QIB:
Investor Affiliation:  


Address 1:  
Address 2:

City:  
County:  
State:
select
 

Zip:
   
Phone:
 
Fax:

Email:
 
Are you employed by the Qualified Indiana Business?  
Is the investor the primary contact for the investment application?
Has the investor received a copy of the QIB Certification letter?    
Primary Contact
First Name:  
Last Name:  
Title:  
Phone:
 
Fax:

Email:  


Investment Information
QIB Information
Company Name:  
Address 1:  
Address 2:

City:  
County:  
State:
select
 

Zip:    

Telephone:  

Fax:


Investment Detail
For this application only, what is the amount of your proposed investment in this company?  

Any current investor who or which holds a majority ownership position prior to the proposed investment in the Qualified Indiana Business generally is not eligible for the VCI tax credit. Any current investor who or which, as a result of making the proposed investment, will hold a majority ownership position generally is eligible for the VCI tax credit for the investment portion up to 50% ownership position. An investor who or which does not hold any ownership position, and does not have a potential ownership position of any kind, prior to making the proposed investment generally is eligible for the VCI tax credit on the entire proposed investment regardless of proposed ownership position.
In what form will your investment be?
select
 

What is your anticipated date on which the proposed qualified investment will be made?
Investments made prior to IEDC approval are not eligible for the VCI tax credit.
 

Please attach a copy of the debt instrument:   
 

Please upload a document that contains a fully diluted ownership positions before and after your proposed investment.