Neighborhood Revitalization Tax Credit Program

Instructions for Submission of Application by Business Entity

This form is intended for use by business entities that are making a contribution of funds to the Neighborhood Revitalization Tax Credit Program (NRTC) and are applying for an equal amount of tax credits, up to the maximum of $1,000,000 per year.

The “Qualified Projects Pool”, publicized at the NRTC website (link below), lists the non-profit organizations with pre-applications that have been determined to be qualified for further funding consideration, along with descriptive information about each qualified project pre-application. Please use the Qualified Projects Pool to make choices on the attached application form:

Specify one organization and funding amount per line in the section labeled, “Qualified Projects Pool Selection.”

The project choices must be listed (ranked) in order of funding preference. This will enable the NRTC Program to allocate funds from a project that has achieved its funding target to other projects that still need funding.

Business entities are encouraged to list multiple organizations as funds recipients.

It will be acceptable for the total amount listed at “Qualified Projects Pool Selection” to be greater than the amount of the funds to be contributed.

The NRTC Program will process applications in the order they are received.

The Department will use 1.5% of the total contribution amount for program administration. The remainder of the contribution will be used for qualified projects. The tax credit certificate will be issued in the amount of the total contribution.

For a business entity that is applying for tax credits with respect to its Gross Income Tax liability (this is restricted to partnerships, limited liability companies and S-Corporations), the “Additional Information” form must also be completed.

Please submit a PDF version by e-mail to of the completed and signed document to Bradley.Harrington@dca.nj.gov, followed by the original, signed version mailed to: ATTN: Bradley Harrington, NJ Department of Community Affairs, Neighborhood Revitalization Tax Credit Program, 101 S. Broad Street, PO Box 811, Trenton, NJ, 08625-0811

The check for your contributed funds must be payable to Treasurer, State of New Jersey, with NJDCA/NRTC Program in the reference line.

Please contact NRTC Program staff with any questions you may have: Bradley Harrington, (609) 633-6273 or Bradley.Harrington@dca.nj.gov.

Link to NRTC website: http://www.nj.gov/dca/divisions/dhcr/offices/nrtc.html

Neighborhood Revitalization Tax Credit Program

Business Entity Application

COMPANY INFORMATION:
Applicant Name	Tax ID#:
Address
City	State	Zip Code
Contact Person	Title
Email	Fax	Phone
Total Contribution: $
Select the tax to which the requested credits will be applied:
☐ Corporate Business Tax	☐ Public Utilities Excise Tax	☐ Gross Income Tax (see instructions)
☐ Insurance Premium Tax	☐ Public Utilities Franchise Tax	☐ Other:
QUALIFIED PROJECTS POOL SELECTION:
Please list the organizations (with qualified projects) and funding amounts, in ranking order, to which your funds would be designated (refer to the instructions). Visit http://www.nj.gov/dca/divisions/dhcr/offices/nrtc.html for a complete list of “Qualified Projects”.
Non-Profit Organization with Qualified Project	Funding Designation Amount
1.	$
2.	$
3.	$
4.	$
5.	$
6.	$
7.	$
8.	$
9.	$
10.	$
Certification:
I, [Name of Officer] of [Name of Firm], hereby affirm under penalties prescribed by the law that this application has been examined by me and to the best of my knowledge and belief, the information is true, correct and complete.
Enter Date _______________________________________________ (Date of Affirmation) (Signature)
Please submit a PDF version by e-mail of the completed and signed document to: Bradley.Harrington@dca.nj.gov Mail the original, signed form to: ATTN: Bradley Harrington NJ Department of Community Affairs Neighborhood Revitalization Tax Credit Program 101 S. Broad Street, PO Box 811 Trenton, NJ, 08625-0811	For DCA Use Only Application Received (Date & Time): ________________ Certificate Issue #: _________________ Date:_________

Neighborhood Revitalization Tax Credit Program

Business Entity Application

ADDITIONAL INFORMATION

This form must be completed by a business entity that is a Partnership, a Limited Liability Company, or an S-Corporation, and that is applying for Neighborhood Revitalization Tax Credits with respect to its Gross Income Tax liability.

Please provide information in the table below, listing: the name of each shareholder/member that would receive tax credit benefit; the ownership stake (by percentage); and the Taxpayer Identification Number (or Social Security Number).

If tax credits are allocated to the business entity, the NRTC program will issue taxpayer-specific certificates to the applicant business entity for distribution to the shareholders/members.

Applicant Name:
Applicant is a: ☐ Partnership ☐ Limited Liability Company ☐ S-Corporation

Shareholder/Member	Ownership Stake (%)	Taxpayer Identification Number (or Social Security Number)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.

For additional Shareholders/Members, duplicate and complete this form.

See Subchapters 2 and 6 of the NRTC Program rules (NJAC 5:47), at the NRTC website, for regulatory requirements and guidance

This amount is equal to the amount of tax credits being requested

All Taxpayer Identification Numbers (or Social Security Numbers) that are submitted on this form are confidential information and will not be freely shared