VENTURE CAPITAL FUND
APPLICATION




SEND TO:

IOWA CAPITAL INVESTMENT BOARD
C/O IOWA DEPARTMENT OF REVENUE
HOOVER STATE O...
APPLICANT INFORMATION

Venture Capital Fund Name:
_______________________________________________________________________
...
GENERAL INFORMATION

House File 2586, adopted by the Iowa Legislature in 2002, provides for an investment tax credit equal...
Des Moines, IA 50319




VENTURE CAPITAL FUND APPLICATION    3
IOWA CAPITAL INVESTMENT BOARD
8. If you have any questions when completing the application, please contact:
              Jim McNulty
              Iowa...
Venture Capital Fund Application.doc
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Venture Capital Fund Application.doc

  1. 1. VENTURE CAPITAL FUND APPLICATION SEND TO: IOWA CAPITAL INVESTMENT BOARD C/O IOWA DEPARTMENT OF REVENUE HOOVER STATE OFFICE BUILDING DES MOINES, IA 50319
  2. 2. APPLICANT INFORMATION Venture Capital Fund Name: _______________________________________________________________________ Contact Name & Title:______________________________________________________ Address:________________________________________________________________ City & State:______________________________________Zip Code:________________ Telephone:_______________________________________Fax:_____________________ E-Mail Address:___________________________________________________________ CERTIFICATION I, the undersigned, on behalf of the venture capital fund identified above, hereby submit the following application to the Iowa Capital Investment Board. I certify that all information, representations, or statements provided to the Iowa Capital Investment Board in connection with this application are true and correct in all material aspects. I understand this application is subject to final approval by the Iowa Capital Investment Board and am aware that the investment tax credit available for investments in venture capital funds are not available until final Board approval is secured. ___________________________________________ Signature, Title ___________________________________________ {Print Name and Title} ___________________________________________ Date VENTURE CAPITAL FUND APPLICATION 1 IOWA CAPITAL INVESTMENT BOARD
  3. 3. GENERAL INFORMATION House File 2586, adopted by the Iowa Legislature in 2002, provides for an investment tax credit equal to 6% of a taxpayer’s equity investment in a venture capital fund. The determination of an eligible venture capital fund is made by the Iowa Capital Investment Board based on the information submitted in this application. The aggregate amount of tax credits issued cannot exceed $5 million. The tax credit for an equity investment in a venture capital fund is available for individual income, corporation income, franchise, insurance premium and moneys and credits tax. For equity investments in a venture capital fund, the credit is available to a partnership, limited liability company, S corporation, estate or trust which elects to have income taxed directly to an individual. The credit claimed by the individual is based upon the pro rata share of the individual’s earnings from the partnership, limited liability company, S corporation, estate or trust. The tax credit shall not be redeemed during any tax year beginning prior to January 1, 2005. The tax credit shall not be claimed prior to the third tax year following the tax year in which the investment is made. Any tax credit in excess of the tax liability can be credited to the tax liability for the following five years or until depleted, whichever is earlier. APPLICATION GENERAL INSTRUCTIONS 1. Before filling out this application form, make sure you have read the Iowa Capital Investment Board administrative rules located in 123-Chapter 3. 2. Complete the application fully; if any questions are left unanswered or required attachments are not submitted, an explanation must be included. 3. Only typed or computer-generated applications will be accepted and reviewed. Send one original completed application form. 4. Use clear and concise language. Attachments should only be used as documentation. 5. Any inaccurate information of a significant nature may disqualify the application from consideration. Information contained in the application is considered public information. 6. This application must be completed within 120 days from the date of the first equity investment (or, for investments made during the 2002 calendar year only, the application must be completed by the later of 120 days from the date of the first equity investment or March 31, 2003). 7. Return the completed application with all required attachments to: Iowa Capital Investment Board c/o Iowa Department of Revenue Hoover State Office Building 1305 East Walnut Street VENTURE CAPITAL FUND APPLICATION 2 IOWA CAPITAL INVESTMENT BOARD
  4. 4. Des Moines, IA 50319 VENTURE CAPITAL FUND APPLICATION 3 IOWA CAPITAL INVESTMENT BOARD
  5. 5. 8. If you have any questions when completing the application, please contact: Jim McNulty Iowa Department of Revenue Hoover State Office Building Des Moines, IA 50319 Phone: (515) 281-6183 E-mail: jim.mcnulty@iowa.gov 9. The Board retains the authority to request additional information and documentation from a venture capital fund at a later date regarding the investments made by the venture capital fund in businesses located in Iowa. The Board may use such information in preparing and publishing any reports to be provided to the governor and the general assembly. APPLICATION INFORMATION 1. The venture capital fund is a private seed and venture capital partnership or entity fund. Please provide a copy of the fund’s certificate of limited partnership, limited partnership agreement, articles of organization or operating agreement certified by the chief executive officer of the venture capital fund. If applicable, include a copy of an “offering document” submitted to the Securities and Exchange Commission. 2. The venture capital fund maintains a physical presence within the state of Iowa. Please provide a signed statement from an officer, director, manager, member of general partner of the fund, stating that the fund maintains a physical presence within Iowa. Physical presence in Iowa includes, but is not limited to, having an office or other business location in Iowa, or having employees or representatives present in Iowa on a regular and continuing basis. 3. The venture capital fund makes a commitment to consider equity investments in businesses located within the state of Iowa. Please provide a signed statement from an officer, director, manager, member of general partner of the fund, stating that a commitment has been made by the fund to consider equity investments in businesses located within Iowa. Please include a copy of any “deal logs” indicating that investments in businesses located in Iowa have been considered. 4. Please indicate the total amount of equity investment that the venture capital fund intends to secure. VENTURE CAPITAL FUND APPLICATION 4 IOWA CAPITAL INVESTMENT BOARD

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