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Angel Investor Tax Credit Application
Qualification Requirements
Are you an accredited investor as defined in the Public Act?
(Required)
An individual who controls less than 50% of the Connecticut business invested in, and:
Your individual net worth or joint net worth with that of your spouse or spousal equivalent exceeds $1,000,000, or
You have an individual net income in excess of $200,000 in each of the two most recent years or joint income with your spouse or spousal equivalent in excess of $300,000 in each of those years and have a reasonable expectation of reaching the same income level in the current year.
A director, executive officer or general partner of the issuer of the securities being offered or sold, or any director, executive officer, or general partner of a general partner of the issuer who controls less than 50% of the issuer.
An organization described in Section 501 (c)(3) of the Internal Revenue Code, corporation, Massachusetts or similar business trust, or partnership, family offices and their family clients, SEC- and state-registered investment advisers, exempt reporting advisers, and rural business investment companies (RBICs)not formed for the specific purpose of acquiring the securities offered by the Connecticut business or providing venture capital financing in general, with total assets in excess of $5,000,000.
A trust, with total assets in excess of $5,000,000 not formed for the specific purpose of acquiring the securities offered, purchase is directed by a sophisticated person as described in Regulation D, Section 230.506(b) of the SEC.
Any entity, including Indian tribes, governmental bodies, funds, and entities organized under the laws of foreign countries, that own “investments,” as defined in Rule 2a51-1(b) under the Investment Company Act, in excess of $5 million and that was not formed for the specific purpose of investing in the securities offered.
A private business development company as defined in Section 202(a)(22) of the Investment Advisors Act of 1940.
An entity which all of the equity owners are accredited investors
A network of accredited investors who review new or proposed businesses for potential investment who may seek active involvement, such as consulting and mentoring, in a Connecticut business.
Natural persons to qualify as accredited investors based on certain professional certifications, designations or credentials or other credentials issued by an accredited educational institution, which the Commission may designate from time to time by order. In conjunction with the adoption of the amendments, the Commission designated by order holders in good standing of the Series 7, Series 65, and Series 82 licenses as qualifying natural persons. This approach provides the Commission with flexibility to reevaluate or add certifications, designations, or credentials in the future. Members of the public may wish to propose for the Commission’s consideration additional certifications, designations or credentials that satisfy the attributes set out in the new rule.
With respect to investments in a private fund, natural persons who are “knowledgeable employees” of the fund.
A bank, savings and loan association, broker or dealer, insurance company, investment company, business development company, SBIC, an employee benefit plan within the meaning of ERISA. Activities of a bank, bank and trust company, insurance company, trust company, national bank, savings association or building and loan association that are part of its normal course of business would not qualify as an accredited investor for the purpose of the angel investor tax credit.
If you do not meet one or more of these qualifications, you do not qualify as an accredited investor.
Application
Name of accredited investor
(Required)
First
Last
Address
(Required)
Street Address
Address Line 2
City
ZIP / Postal Code
Contact name
(Required)
First
Last
Phone
(Required)
Email
(Required)
SSN or FEID no.
(Required)
Name of Qualified Connecticut Business to receive cash investments eligible for an Angel Investor Tax Credit
(Required)
Amount of investment
(Required)
Please enter a number greater than or equal to
25000
.
Must be $25,000 or greater and made in cash. Proof of investment must be submitted to Connecticut Innovations prior to issuance of Angel Investor Tax Credit
Angel investor tax credit requested (25% of cash investment). Maximum credit available to any one angel investor shall not exceed $500,000. The credit shall be claimed in the taxable year in which the investment is made.
Are you bearing all of the risk of loss in this investment?
(Required)
Yes
No
Type of qualified security to be issued
(Required)
General Partnership Interest
Limited Partnership Interest
Common Stock
Preferred Stock (must be convertible to common stock)
Other form of Equity
Please describe any other forms of equity
(Required)
Expected date of investment in Qualified Connecticut Business
(Required)
MM slash DD slash YYYY
Consent
(Required)
I agree to the privacy policy.
The undersigned acknowledges and agrees that
1. Connecticut Innovations, Incorporated (“CI”) and the State of Connecticut (a) have not endorsed or recommended an investment in the issuer; (b) have not made any representation or warranty of any kind with respect to the value of the issuer’s securities, the financial condition or the future earnings of the issuer, the management of the issuer or the issuer’s business or prospect; and (c) will bear no responsibility for any investment losses or other damages that may be suffered as a result of an investment in the issuer.
2. The listing by CI of the Issuer as a “Qualified Connecticut Business” means only that CI has determined, based solely on information provided by the issuer, that the issuer meets the statutory requirements for approval as a Connecticut business qualified to receive cash investments eligible for a Connecticut income tax credit pursuant to the Public Act (the “Act”). The availability, amount and value of such a tax credit to a particular taxpayer is a function of other provisions of the Act and the taxpayer’s own individual tax situation, as to which the undersigned should look to their own tax advisor for advice.
3. CI is a “public agency” for purposes of the Connecticut Freedom of Information Act (“FOIA”). Accordingly, upon receipt at the office of CI, any application under the Connecticut Angel Investor Tax Credit Program will be considered a public record or file subject to disclosure under the FOIA. The FOIA includes exemptions for “trade secrets” and “commercial or financial information given in confidence, not required by statute.” In addition, all financial and credit information and all trade secrets contained in an application for financial assistance or obtained by CI concerning any applicant for financial assistance or any project, activity, technology, product or invention is exempt from disclosure under FOIA. Only the particular information falling within one of these exemptions can be withheld by CI if made the subject of a public records request under FOIA. Therefore, an applicant under the Connecticut Angel Investor Tax Credit Program should specifically identify those particular sentences, paragraphs, pages, sections or exhibits that it claims to be exempt. Applicants should be aware that (i) CI has no obligation to notify any applicant of any FOIA request received by CI; (ii) CI may disclose materials claimed to be exempt if in its judgment such materials do not appear to fall within a FOIA exemption; (iii) CI may in its discretion notify applicants of FOIA requests and/or of complaints made to the Freedom of Information Commission concerning items for which an exemption has been claimed, but CI has no obligation to initiate, prosecute or defend any legal proceeding or to seek to secure any protective order or other relief to prevent disclosure of any information pursuant to an FOIA request, (iv) the applicant will have the burden of establishing the availability of any FOIA exemption in any such legal proceeding, and (v) in no event shall CI or any of its officers, directors or employees have any liability for disclosure of documents or information in the possession of CI which CI, or such officer, director or employee, in good faith believes to be required pursuant to the FOIA or other requirements of law. In the event of a public records request for an application under the Connecticut Angel Investor Tax Credit Program, CI may request, and each applicant agrees promptly to provide to CI, a version of such application from which all information for which an FOIA exemption has been claimed has been redacted. Except for trade secret or other proprietary information identified as such pursuant to the section above dealing with the Freedom of Information Act, CI is not restricted in its right to use or disclose any or all of the information contained in any application and can do so without compensation to the applicant, notwithstanding any language in the application to the contrary.
Signature
(Required)
Printed name of above signer
(Required)
Angel Investor Tax Credit Reservation Numbers are issued on a first come, first serve basis based upon the date that Connecticut Innovations receives this application, not based on the date the investment is made by the investor.
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