Revised December 2012 - Page 1 of 2 

VERIFICATION OF CONTRIBUTION TO A MISSOURI CERTIFIED INCUBATOR 
SMALL BUSINESS INCUBATOR TAX CREDIT PROGRAM, SECTION 620.495 RSMo 

To receive a tax credit under the Small Business Incubator Program, the taxpayers who contribute to a certified Missouri incubator, must complete 
this form for each contribution and send to the department for review along with documentation satisfactory to the department. 

                                     Tax Year Beginning                    /                /            Tax Year Ending                  /                / 
                                    NAME OF INDIVIDUAL ENTITY                                                              FEDERAL TAX ID NUMBER 

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

                                    CITY                                   STATE                    ZIP                    SOCIAL SECURITY NUMBER 

                                    TELEPHONE NUMBER                                   FACSIMILE NUMBER                         EMAIL ADDRESS 
                                    (               )               –                  (               )               – 

                                    Business Entity for Tax Purposes: 
                                      Corporation                      S-Corporation          Partnership                 Individual            Other 
                  1. CONTRIBUTOR    Note: If a taxpayer is a Corporation, Partnership, S-Corporation or Other, identify the names, social security numbers, and proportioned share 
                                    of ownership of each beneficiary, partner, or shareholder on the last day of the tax period. Aggregate proportionate shares or percent of total 
                                    ownership may not exceed 100%. Attach a separate sheet if necessary. 
                                                                      Name                               Social Security Number                   % Ownership 
                                                                                                                                                                                    % 
                                                                                                                                                                                    % 
                                                                                                                                                                                    % 
                                                                                                                                                                                    % 
                                    FIRST NAME                                          MIDDLE NAME                             LAST NAME 

                                    ADDRESS (STREET, PO BOX) 

                                    CITY                                                                STATE                                     ZIP 

                                    TELEPHONE NUMBER                                    FACSIMILE NUMBER                        EMAIL ADDRESS 
                  2. CONTACT PERSON 
                                    (               )               –                   (               )               –  

                                    Contribution was made in (check one): 
                                      CASH                                                               NON-CASH 
                                    Amount                                                                                      Date 
                                    $  _______________________________________________________________________                                    /                / 
                  3. CONTRIBUTION   Note: For cash contributions, provide a cancelled check, bank statement, or wire transfer. For non-cash contributions, please refer to the policy 
                                    guidelines of the Small Business Incubator Program, “Eligible Contributions.” 

Revised December 2012 - Page 2 of 2 

• I certify that I am an authorized representative of the applicant and as such am authorized to make the statement of affirmation 
contained herein. 
• I certify that the applicant does NOT employ illegal aliens and that the applicant has complied with federal law (8 U.S.C. § 1324a) 
requiring the examination of an appropriate document or documents to verify that an individual is not an unauthorized alien. 
• I understand that if the applicant is found to have employed an illegal alien in Missouri and did not, for that employee examines the 
document(s) required by federal law, that the applicant shall be ineligible for any state-administered or subsidized tax credit, tax 
abatement or loan for a period of five years following any such finding. 
• I attest that I have read and understand the Small Business Incubator Tax Credit Program guidelines, specifically as it relates to the 
Tax Credit Accountability Act of 2004 (SB 1099). 
• I hereby agree to allow representatives of the Department of Economic Development access to the property and applicable records as 
4. CERTIFICATION may be necessary for the administration of this program. 
• I certify under penalties of perjury that the above statements, information contained in the application and attachments are complete, 
true, and correct to the best of my knowledge and belief 
Must be signed in the CONTRIBUTOR’S SIGNATURE DATE 
presence of a notary.  /                / 
NOTARY EMBOSSER SEAL STATE COUNTY MY COMMISSION EXPIRES 

On this          day of            , 20     , before me,                                               , a Notary Public 
in and for said state, personally appeared                                                    , known to me to be 
the person who executed the Certification and acknowledged and states on his/her oath to me 
that he/she executed the same for the purposes therein stated. 
5. SIGNATURE 
NOTARY PUBLIC SIGNATURE NOTARY RUBBER STAMP 

NAME OF INCUBATOR 

ADDRESS (STREET, PO BOX) 

CITY STATE ZIP 

TELEPHONE NUMBER FACSIMILE NUMBER 
(               )               – (               )               – 

I have examined this application and all attachments and believe it to be an accurate description of the contribution received by our 
organization for the purposes of carrying out this application project. 
6. INCUBATOR’S VERIFICATION INCUBATOR’S SIGNATURE DATE 
 /                / 

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