Form RPD-41325 Laboratory with Small Business Tax Credit

A Small business name Name of the recipient of the small business assistance A written copy of the joint small business joint assistance operational plan has been submitted to the Department Action Dates Completed APPLICATION FOR LABORATORY PARTNERSHIP WITH Attach Schedule A Recipient of Small Business Assistance Detail Report (See the field descriptions below ) Authorized Signature Title Date B Small business address Address of the recipient of the small business assistance C County County in which the recipient of the small business assistance is located Consulted with the Secretary of Economic Development to seek advice on improvements in the operation of the small business assistance program; D Start date Date the small business assistance project began E Completion date Date the National Laboratory receives acknowledgement from the small business that the assistance was rendered Established a methodology to utilize contractors who have demonstrated the capability to provide small business assistance; and Established a revolving fund with initial funding from a source other than tax credits; Established a small business assistance program; F Availability of assistance certification received The recipient of the small business assistance provided a certified statement to the National Laboratory that the assistance is not otherwise available at a reasonable cost through private industry F G H G Availability of assistance verified by the National Laboratory The National Laboratory tested the assistance project assuring that the assistance provided was not otherwise available to the small business at a reasonable cost through private industry H Notice of ownership options provided to recipient Notice was provided to recipient of option to obtain ownership of or license to tangible or intangible property developed from the small business assistance I CERTIFY THAT pursuant to the Laboratory Partnership with Small Business Tax Credit Act the national laboratory named above has complied with all requirements to be eligible to claim the credit including: I Qualified expenditures allowed The expenditures of the assistance provided limited to the following: Employee salaries wages fringe benefits and employer payroll taxes; administrative costs related directly to the provision of small business assistance the total of which is limited to 49% of employee salaries wages fringe benefits and employer payroll taxes; in state travel ex penses including per diem and mileage at the IRS standard rates; and supplies and services of contractors related to the provision of small business assistance Enter the sum of qualified expenditures not to exceed $10 000 if the small business is located outside of a rural area for which small business assistance is rendered or $20 000 if the small business assistance was provided to a small business located in a rural area This is the total allowable expenditures related to the amount of small business assistance provided for which the National Laboratory may claim the credit LABORATORY PARTNERSHIP WITH SMALL BUSINESS TAX CREDIT Mail this form and the CRS 1 return to which the credit is to be applied to: New Mexico Taxation & Revenue Depart Mailing address City/state/ZIP ment ATTN: Director s Office P O Box 8485 Albuquerque New Mexico 87504 8485 For assistance call (505) 476 3683 Name of contact person Phone number E mail address Name of national laboratory CRS identification number Page of REQUESTED: Enter the amount of Laboratory Partnership with Small Business Tax Credit requested $ (Enter the sum of the amounts reported in Column K of Schedule A Recipient of Small Business Assistance Detail Report ) If approved this is the amount of your laboratory partnership with small business tax credit The total amount of laboratory partnership with small business tax credit may not exceed $2 400 000 in a calendar year Rev 02/2011 RPD 41325 State of New Mexico Taxation and Revenue Department SCHEDULE A RECIPIENTS OF SMALL BUSINESS ASSISTANCE DETAIL REPORT Small business name A Small business address B County C Start date D Completion date E See field descriptions Enter yes or no to indicate action taken Qualifi ed expenditures allowed I SMALL BUSINESS TAX CREDIT State of New Mexico Taxation and Revenue Department Under penalty of perjury I delare I have examined this application including accompanying invoices schedules and/or statements To the best of my knowledge and belief this application is true correct and complete