Massachusetts Department of Revenue
                                                 Form LOA
                                                 Loan-Out Affidavit/Allocation                                                                                                                                                            2020

Production company is required to complete and submit a separate loan-out affidavit for every personal service or loan-out company included on
the film credit application. Failure by production company to fully complete and submit a fully signed loan-out affidavit for a personal service or
loan-out company will result in disallowance of the credit claimed in relation to such personal service or loan-out company. To be valid and ac-
cepted, this form must be signed by an authorized representative from the loan-out company, the actor/performer and the production company.

General Information
Production company name                                                                                                    Federal Identification number

Mailing address                                                                                                                      City/Town                                                                      State              Zip

Name of production

Massachusetts production start date (mm/dd/yyyy)                                                       Massachusetts production end date (mm/dd/yyyy)

Personal Service/Loan-Out Company Information
Company name                                                                                                                      Federal Identification number

Business address                                                                                                                   City/Town                                                                      State              Zip

Mailing address (if different)                                                                                                   City/Town                                                                      State              Zip

Name of authorized representative                                 Title                                                Telephone                                                                     E-mail

Massachusetts start date (mm/dd/yyyy)                                                                                Massachusetts end date (mm/dd/yyyy)

Fill in if company is registered with Massachusetts Secretary of State to do business in Massachusetts.
Fill in if company is registered with Massachusetts Department of Revenue (DOR) to file and pay taxes.
If either of these are not filled in, the company will be required to register with Massachusetts Secretary of State and DOR.
I declare under the pains and penalties of perjury that to the best of my knowledge, the information contained herein is accurate and complete.
Signature                                                                          Title                                                Name                                                                            Date

Actor/Performer Information. Attach additional sheets if more than one actor/performer is provided by this loan-out.
Name of actor/performer providing loan-out services                                                           Social Security number

Residential address                                                                                                                City/Town                                                                      State              Zip

Mailing address (if different)                                                                                                   City/Town                                                                      State              Zip

Massachusetts start date (mm/dd/yyyy)                                                                                Massachusetts end date (mm/dd/yyyy)

Fill in if the actor/performer is registered with DOR to file and pay taxes.
If this is not filled in, the actor/performer will be required to register with DOR and file a personal tax return.
I declare under the pains and penalties of perjury that to the best of my knowledge, the information contained herein is accurate and complete.
I also understand and agree to comply with the Motion Picture Production Company Withholding Regulation 830 CMR 62B.2.3 Sec. 5(b).
Signature                                                                                                                                Name                                                                            Date

Be sure to complete page 2.

                                                                                                   2020 SCHEDULE LOA, PAGE 2

Payments to Loan-Out Company
1 Total amount paid by production company to personal service/loan-out company for overall production. . . . . . . . . . . . . . . . . . .                                                         1
2 Total amount paid by production company to personal service/loan-out company for qualifying Massachusetts payroll/
  production credit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3 Fill in if all payments on line 2 by the production company to this loan-out are Massachusetts source income relating to services for this production. 
4 Fill in the company is registered for Massachusetts motion picture performer withholding tax.
5 Total amount of Massachusetts withholding tax remitted to Massachusetts relating to this loan-out company. . . . . . . . . . . . . . . 5
6 Dates the personal service/loan-out company performed service on this production in Massachusetts
Start date (mm/dd/yyyy):                                                                                      End date (mm/dd/yyyy):
7 Date(s) withholding payment remitted to Massachusetts Department of Revenue

I declare under the pains and penalties of perjury that to the best of my knowledge, the information contained herein is accurate and complete.
Signature                                                                          Title                                                Name                                                                            Date

Mail to Massachusetts Department of Revenue, Audit Division, 200 Arlington Street, Room 4300, Chelsea, MA 02150, attn.: Film Credit Unit.

                                          Form LOA Instructions

What is the Loan-Out Affidavit?                                         Payments to Personal Service/Loan-out
The Loan-Out Affidavit is a form the production company is required     Companies
to complete and submit for each and every personal service/loan-        To be completed by the production company.
out company whose wages are included on the Film Credit Applica-
tion. Failure by the production company to complete and submit a        Line 1
Loan-Out Affidavit for a personal service/loan-out company will re-     Enter the total amount of wages paid to the personal service/loan-
sult in disallowance of the credit claimed in relation to such per-     out company for the production everywhere.
sonal service/loan-out company.                                         Line 2
Note: The affidavit must be completed in full and signed with origi-    Enter the total amount of qualified wages paid to the personal serv-
nal signatures by an authorized representative of the production        ice/loan-out company for the production in Massachusetts.
company, an authorized representative of the personal service/          Line 3
loan-out company and the actor/performer in order to be valid and
                                                                        Fill in to verify that all wages paid to the personal service/ loan-out
accepted.
                                                                        company are for services performed in Massachusetts and consti-
Who Must File a Loan-Out Affidavit?                                     tute Massachusetts source income to the personal service/loan-out
Production companies who are claiming wages for amounts paid to         company.
personal service/loan-out companies on the Massachusetts Appli-         Line 4
cation for Payroll/Production Credit must file the affidavit with their Under 830 CMR 62B.2.3, the production company is required to
application for credit. A separate Loan-Out Affidavit must be com-      register and withhold on payments made to loan-out companies.
pleted and filed with the Massachusetts Application for Payroll/Pro-    Fill in to verify that the production company has complied with the
duction Credit for each personal service/loan-out company included      regulation.
on the application for credit.
                                                                        Line 5
Note: A copy of the signed affidavit should be retained by the loan-
                                                                        Enter the total amount of Massachusetts withholding tax remitted to
out company and the actor/performer for their records and to attach
                                                                        Massachusetts relating to the wages paid to this loan-out company.
to their Massachusetts income tax returns as required.
                                                                        Line 6
General Information
                                                                        Enter the range of dates that this loan-out company performed serv-
Complete the general information section of this application with the
                                                                        ices in Massachusetts relating to the wages on line 2.
information requested. On the Massachusetts production informa-
tion line, enter the first date that the production company did work in Line 7
Massachusetts and the final day the production company did work         Enter the date or dates withholding tax payments were made to
in Massachusetts on this production.                                    Massachusetts.
Personal Service/Loan-out Company Information                           Note: The completed form must be filed with the Application for Pay-
This section is to be completed and signed by an authorized repre-      roll/Production Credit.
sentative of the personal service/loan-out company.  All sections
must be completed in order for the wages to be included on the pro-     Mail to Massachusetts Department of Revenue, Audit Division,
duction company’s credit application. The Massachusetts start and       200 Arlington Street, Room 4300, Chelsea, MA 02150, attn. Film
end dates are the first date that the personal service/loan-out com -   Credit Unit.
pany did work in Massachusetts and the final day the personal serv-
ice/loan-out company did work in Massachusetts on this production.
Actor/Performer Information
This section is to be completed and signed by the actor/performer.
All sections must be completed in order for the wages to be included
on the production company’s credit application. The Massachusetts
start and end dates are the first date that the actor/performer did
work in Massachusetts and the final day the actor/performer did
work in Massachusetts on this production.