Angel Tax Credit Request Form

SECTION I. Individual Angel or Angel Entity Information

Individual Angel, Angel Network or Angel Entity Name:(Required)

Individual Angel, Angel Network or Angel Entity Address (city,state,zip):(Required)

Email :(Required)

Telephone number:(Required)

FEIN or SSN#:(Required)

Connecticut tax registration:(Required)

Only for Angel Entity & if different from above

Skip if it does not apply.

Network/entity contact name:

Network/entity address (city,state,zip):

Email :

Telephone number:

SECTION II. Qualified Connecticut Business (QCB) Information

Qualified Connecticut Business Name:(Required)

Contact name:

Telephone number:(Required)

Email:(Required)

Connecticut tax registration:(Required)

SECTION III. Attachments

Please attach the following for this investment.

Copy of the signed Investor Agreement documenting the investment and any other documents as requested by Connecticut Innovations:(Required)

Drop files here or

Max. file size: 50 MB.

Copy of the Investor’s or Entity’s wire transfer or check from Investor's account with account name:(Required)

Drop files here or

Max. file size: 50 MB.

Copy of the QCB’s bank statement showing the deposit(s) made with QCB’s name on statement:(Required)

Drop files here or

Max. file size: 50 MB.

SECTION IV. Qualified Connecticut Business Attestation

I hereby attest that the individual investor, angel or entity named below made a cash investment in the amount entered and that these funds were deposited and available for use by the QCB on the date entered and not prior to the QCB certification date provided below.

Individual Investor, Angel or Entity Name:

Cash invested (excludes debt/inkind):(Required)

Date deposited and available to the QCB*:(Required)

*If funds were escrowed, fill in the date the funds came out of escrow and were available for use by the QCB.

QCB certification date:(Required)

QCB Treasurer Name:(Required)

Signature(Required)

Date(Required)

Investor List(Required)

First, MI, Last Name

Mark X if Accredited Investor

Social Security Number

Investment Amount

You can add up to 10 individual investors.

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