Angel Tax Credit Program

Qualified Investor Certification Application Form
Certification for Calendar Year 2014

Data Privacy Notice: per Minn. Stat. 116J.8737, Subd. 8, all data provided in this application is private data; certain information becomes public upon certification as a qualified investor, upon a credit allocation, and upon a credit revocation. Qualified investor’s names will be posted on the department’s website.

Tennessen Warning Notice: per Minn. Stat. 13.04, Subd. 2, this data is being requested from you to determine if you may be certified as a qualified investor eligible to apply for tax credits under the Angel Tax Credit Program. You are not required to provide the requested information, but failure to do so may result in the department’s inability to certify you as a qualified investor. Upon qualification and granting of tax credits under the Angel Tax Credit Program, this information will be shared with the Minnesota Department of Revenue.

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Sections

I. Identifying Information
II. Accredited Investors
III. Non-Accredited Investors
IV. Certifications

Section I. Identifying Information    Top

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* Name
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*COMPLETE ONLY SECTION II OR SECTION III, WHICHEVER IS APPLICABLE:

Section II. Accredited investors per SEC Rule 501 (natural persons only)    Top

(Check all that apply)



OR

Section III. Investors who are not accredited investors (natural persons only)    Top

(check all that apply)
 Minn. Stat. 80A.46 clauses (13) or (14).
 Minn. Stat. 80A.50 (b).

Section IV. Certifications    Top

Disclaimer
I certify that I have been advised, acknowledge, and understand that no action taken by the State of Minnesota or by any employee, agent or official of the State has been intended or shall be construed to:
a. constitute an endorsement or recommendation of the business, or its business activities, or of any financial investments made or proposed by any person or entity in the business, as a result of or related to the business’ certification, by the State’s commissioner of employment and economic development ("Commissioner") as a qualified business pursuant to the provisions of Minn. Stat. 116J.8737 ("the Angel Tax Credit Program");
b. constitute an endorsement or recommendation of the financial condition of, or of the business activities of, any investor or fund that has been certified by the Commissioner as either a certified investor or certified fund under the Angel Tax Credit Program;
c. provide any assurance that the business as a certified small business, or any investor or fund certified as a qualified investor or qualified fund, or any investment classified as a qualified investment, under the Angel Tax Credit Program, is in compliance with any and all applicable federal and state securities laws and regulations; or
d. relieve the business or any person or business entity associated with it from any obligation to comply in full with the requirements of any and all applicable federal and state securities laws and regulations.
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