Revised December 2012 - Page 1 of 4 

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    NUMBER OF UNITS 
                                                                                   ___________Sq. Feet          ___________Sq. Feet 

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

                          ALLIANCES, PARTNERSHIPS AND SPONSORS 

                          ORGANIZATIONAL STRUCTURE 

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

  Number of Jobs # (created/maintained)   Total Payroll  $ 
TARGET MARKETS 

SERVICES OFFERED 

ENTRANCE CRITERIA 

SUCCESS GRADUATION CRITERIA 
 
FAILURE EXIT CRITERIA 

1. INCUBATOR

CURRENT OCCUPIED CAPACITY (%) 
 

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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) 
  Occupancy Size (%) 
  Expected Graduation Date 

2. TENANTS   Business Description 
  Recent Developments 
  Other 
The following information is required (total for all tenants): 
  Number of Jobs # (created/maintained)   Total Payroll  $ 
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 
3. MISSOURI GRADUATES The following information is required (total for all graduates): 
  Number of Jobs # (created/maintained)   Total Payroll  $ 

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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 
4. OTHER GRADUATES   Reasons Why the Company Decided to Leave Missouri 
In a separate document, please provide the following information for each failed company: 
  Name 
  Occupancy Length (years) 
  Date and Reasons for Failure 
5. FAILED TENANTS   Business Description 
  Recent Developments 
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