Revised September 2018 - Page 1 of 5 

MISSOURI CERTIFIED INCUBATORS ANNUAL PERFORMANCE REPORT 
FOR FISCAL YEAR ENDING JUNE 30 
                                                                                              DUE: SEPTEMBER 30 
                            NAME OF INCUBATOR                                                 FEDERAL TAX ID NUMBER 

                            ADDRESS (STREET, PO BOX)                                          MITS/MISSOURI TAX ID NUMBER 

                            CITY                                 STATE         ZIP            NAICS CODE  

                            CONTACT PERSON’S NAME  

                            TELEPHONE NUMBER                     FACSIMILE NUMBER             EMAIL ADDRESS 

                            YEAR ESTABLISHED  YEAR CERTIFIED     BUILDING SIZE       RENTABLE UNIT SIZE 
                                                                 ___________Sq. Feet ___________Sq. Feet
                            TOTAL # OF RENTABLE UNITS                                # OF UNITS CURRENTLY VACANT 

                            Focus: 
                            
              N1. INCUBATOR   Product                   Product Development    Research and            Business Development Services
                            Manufacturing                                      Development
                             Other  _____________________________________________________________________________________________________
                            MISSION 

                            ALLIANCES, PARTNERSHIPS AND SPONSORS 

                            ORGANIZATIONAL STRUCTURE 

                                                                              Revised September 2018 - Page 2 of 5 

                  Please provide additional information (if any) related to your incubator such as Recent Developments, Awards, Future Tenants, 
                  etc.: 

                   Number of Incubator Jobs created within the current
                  Reporting Period
                   Total Number of Incubator Jobs Maintained
                  (These numbers should represent employees of the incubator) 

                  TARGET MARKETS 

                  SERVICES OFFERED 

                  ENTRANCE CRITERIA 

         INCUBATOR
         1.       SUCCESS GRADUATION CRITERIA 

                  FAILURE EXIT CRITERIA 

                                                                                 Revised September 2018 - Page 3 of 5 
        CURRENT OCCUPIED CAPACITY (%) 

        SOURCE OF FUNDING             NAME OF ALL PROGRAMS UTILIZED OR BEING UTILIZED TOTAL AMOUNT 

        FEDERAL 

        MISSOURI 

        LOCAL 

        PRIVATE 

        OTHER 

        TOTAL                                                                         $ 

        In a separate document, please provide information for each tenant, including whether a company came from another state or 
        country, and explain why that company chose Missouri and your incubator: 
         Name
         Contact Information
         Occupancy Length (years)
        
TENANTS   Occupancy Size (%)
2.       Expected Graduation Date
         Business Description
         Recent Developments
         Other

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The following information is required (total for all tenants): 
  Number of Jobs created by the Tenants within the Current  
Reporting Period. 
  Number of Jobs Maintained by the Tenants since inception 
at the Incubator 
In a separate document, please provide information for each graduate that operates in Missouri: 
  Name 
  Contact Information 
  Occupancy Length (years) 
  Date of Graduation 
  Business Description 
  Recent Developments 
  Reasons Why the Company Decided to Stay in Missouri 
The following information is required (total for all graduates): 
  Number of Jobs # (created/maintained)  
  Number of Tenants graduated within the current reporting  
period 
  Number of Tenant Jobs  for each graduate company created 
3. MISSOURI GRADUATES within the current reporting period 
  Total Number of Tenant Jobs maintained through 
graduation? 
  Will the company continue to operate post graduation? 
  Where did the Graduate Locate within Missouri? Include 
reasons for staying in MO. 
   
In a separate document, please provide information for each graduate that left Missouri: 
  Name 
  Contact Information 
  Occupancy Length (years) 
  Date of Graduation 
  Business Description 
  Recent Developments 
  Reasons Why the Company Decided to Leave Missouri 

4. OTHER GRADUATES   Where did the company relocate? 
  Number of tenant jobs that were lost due to relocation outside Missouri? 
 
5. FInAIa separateL E D document,T E N A pleaseN T S provide the following information for each failed company: 

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   Name 
   Occupancy Length (years) 
   Date and Reasons for Failure 
   Business Description 
   Recent Developments 
   Number of tenants that failed within the Reporting period (include # of Tenant jobs lost for each company at the time of 
 failure) 
   Total number of  tenants that failed since the inception of the Incubator (include # of tenant jobs lost for each failed company) 
  
                                 RETURN TO: 
                                 Department of Economic Development 
                                 Division of Business and Community Services 
                                 Finance Management 
                                 301 West High Street, Room 770 
                                 P.O. Box 118 
                                 Jefferson City, MO 65102