R-1039 (1/15)
                                                                                                             Mail:
                                                                                                             Office Audit Division
                                    Enterprise Zone or Quality Jobs Refundable                               Economic Development Unit
                                                                                                             P. O. Box 66362
                           Investment Income Tax Credit Claim for Refund                                     Baton Rouge, LA  70896-6362
                                                                                                             225.219.2270
                                                                                                             LDR.TaxIncentives@LA.gov

                                                                                               Date of Claim (mm/dd/yyyy)

                                                                                                                         PLEASE PRINT OR TYPE.
LA Revenue Account Number                                                  Project Contract No.

Legal Name of Business                                                     Trade Name of Business

Mailing Address                                                            Project Location Address

City                       State        ZIP                                City                              State       ZIP

Project Completion Date (Date Indicated on Project Completion Report)      Date Project Completion Report Signed by Board of Commerce and Industry

                                            Total Qualified Expenditures
     Amounts classified as capital expenditures for federal income tax purposes that are re-
     lated to the contract project and are placed in service from the beginning of construction 
1                                                                                                  1
     until the date of project completion (Other related capitalized intangible expenditures such 
     as architectural and engineering costs prior to construction are includible.)  
     PLUS: Amounts that would have been capitalized but for exclusions from capitalization as 
2                                                                                                  2
     provided in IRC §263(a)(1)(A) – (L)
     LESS: The capitalized cost of land, land leases, interest, purchase of an existing building 
     (except any properly capitalized costs of rehabilitation) and manufacturing machinery and 
3                                                                                                  3
     equipment (to the extent the capitalized manufacturing machinery and equipment costs 
     are excluded from sales and use tax under R.S. 47:301(3))
     PLUS: The  capitalized basis  of qualified  expenditures properly reduced by claiming  a 
4                                                                                                  4
     federal credit
5    Total qualified expenditures                                                                  5

6    Applicable percentage                                                                         6                        X         .015
7    REFUNDABLE INVESTMENT TAX CREDIT – Multiply Line 5 by Line 6.                                 7

This claim may be filed only after the project completion report is signed by the Board of Commerce and Industry. Attach 
schedules that detail the qualified expenditure amounts reported on Lines 1, 2, 3, and 4 and copies of the fully executed Project 
Completion Report and the Enterprise Zone or Quality Jobs contract.

                                            Declaration
I declare that to the best of my knowledge of all available information, this refund claim is true and complete and complies with all 
statutes, rules and regulations, and any other policy pronouncements related to the Enterprise Zone program refundable investment 
income tax credit.
Signature of Officer, Owner or Other (for Other, attach Power of Attorney)      Date (mm/dd/yyyy)
X
Print Name                                                                      Title

Contact Telephone Number                                                        Email Address
(    )

                                                                                                                                        ITC