Form 8942 Application for Certification of Qualified Investments E

Form

8942

(June 2010)
Department of the Treasury
Internal Revenue Service

Part I

Application for Certification of Qualified Investments
Eligible for Credits and Grants Under the Qualifying
Therapeutic Discovery Project Program
▶ See

OMB No. 1545-2175

separate instructions for required attachments.

Applicant Information

1

Name of applicant

3

Number and street

4

City, town, or post office, state, and ZIP code

Check if this is an amended application

2 Taxpayer identification number (TIN)
Room/suite

5
6
7

Telephone number
URL address for applicant's website
Is the applicant a member of an affiliated group filing consolidated returns? . .
If "Yes," complete lines 8 through 12.
8
This corporation has been a member of this group:
a
For the entire year
From
/
/ 20
until
/
/ 20
.
b
9
Name of the common parent of the affiliated group

.

.

.

.

.

.

.

Yes

No

10 Employer identification number (EIN)

11

Number and street

12

City, town, or post office, state, and ZIP code

13

Contact person. Attach a properly completed Form 2848, Power of Attorney and Declaration of Representative, if necessary.
See instructions.

Room/suite

a Name of contact person
b Number and street
c

Room/suite

City, town, or post office, state, and ZIP code

d Telephone number

e

Fax number

14a Name of the project
b Description of the project (see instructions)

Part II
15

16

Certification and Grant Election Information (see instructions)

Enter the number of employees in all businesses of the applicant on the date this application is
submitted. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . ▶
If more than 250, do not continue with this application.
Are the applicant and any other entities considered to be a single employer under section 52(a) or (b) or
section 414(m) or (o)? See instructions . . . . . . . . . . . . . . . . . . . . . ▶
Yes
No
If "Yes":
• Attach a statement listing the name, address, and employer identification number (EIN) for each of the other entities; and
• Applicant certifies it has 250 or fewer employees, taking into account the employees of these other entities, on the date this
application is submitted.

17

Is the applicant electing for this application for certification to be an application for a grant for a tax year beginning in:
If "Yes" for either a or b, complete lines 18 and 19.
a 2009?
Yes
No
If "No" to both a and b, skip to line 20.
b 2010?
Yes
No
18
Enter the applicant's Data Universal Numbering System (D-U-N-S) number. See instructions. ▶
19

Check the applicable box that describes the applicant. If any of the following describes the applicant, the applicant is not
eligible for a grant.
Federal, state, or local government or any political subdivision, agency, or instrumentality thereof.
Organization described in section 501(c) and exempt from tax under section 501(a).
Entity referred to in section 54(j)(4).
Partnership or other pass-through entity with a government or any political subdivision, agency, or instrumentality thereof, section
501(c) organization, or section 54(j)(4) entity as a direct or indirect partner (or other direct or indirect holder of an equity or profits
interest). Note: Do not check this box if such entity owns only an indirect interest in the applicant through a C corporation.

For Privacy Act and Paperwork Reduction Act Notice, see instructions.

Cat. No. 37758D

Form 8942 (6-2010)

Page 2

Form 8942 (6-2010)

Part II
20
21

Certification and Grant Election Information (continued)

Yes
No
Will this project create and sustain (directly or indirectly) high-quality, high-paying jobs in the United States?
Enter the number of full-time and part-time employees in the United States whose work is directly billed to the project and the
average salaries of the employees in each category. See instructions.
Employees

a
b
22a
b
c
23
24
25

Number of employees

Average salaries of the employees

Full-time
Part-time
Enter the number of contractors in the United States paid for work on the project . . . . . . .
Enter the average monthly hours of the contractors entered on line 22a . . . . . . . . . .
Enter the average monthly compensation of the contractors entered on line 22a. . . . . . . .
Will this project advance United States competitiveness in the fields of life, biological, and medical
sciences? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
As of the date this application is submitted, is the project active, terminated, or suspended? Check one.
Active
Terminated
If the project is terminated or suspended for any of the failures below, check all boxes that apply.
The project failed a clinical trial.
The project failed a pre-clinical research milestone.
The project failed to secure FDA licensure.
If the applicant checked any of the boxes above, do not continue with this application.

Yes

No

Suspended

26

Will the project produce a new or significantly improved technology, or a new application of or significant
improvement to existing technology, as compared to commercial technologies currently in service? .

Yes

No

27

Is the project expected to lead to the construction or use of a contract production facility in the United
States in the next 5 years? . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

No

Part III

Qualified Investment (see instructions)

Complete columns (a), (b), and (c), as
applicable. See instructions.
Complete column (a) only for 2009 grant
applications if the applicant's 2009 tax year ends
after the application date.

(a)
As of September 30, 2010
(tax year 2009 only)
(see instructions)

(b)
Tax year 2009

(c)
Tax year 2010

28

Qualified investment derived
from employee wages.

29

Qualified investment derived
from supplies and lab costs.

30

Qualified investment derived
from depreciable property.

31

Qualified investment derived
from third-party contractors.

32

Qualified investment derived
from other costs.

33

Amount in line 30 attributable to
qualified progress expenditures.

34

Total. Add lines 28 through 32 in
each column.
Qualified investment for which certification is requested. Add line 34 columns (b) and (c).
This application is for certification of qualified investment, related to a qualifying therapeutic discovery project, for (check only one):
Tax year beginning in 2009 only. Enter the ending date of the tax year . . . . . . . . ▶
/
/
Tax year beginning in 2010 only. Enter the ending date of the tax year . . . . . . . . ▶
/
/
Tax years beginning in 2009 and 2010. Enter the ending date of the tax year for 2009 . . . ▶
/
/
/
/
and for 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . ▶

35
36

Sign Here
Keep a copy
of this form
for your
records.

Date

Signature of Applicant
Preparer’s
signature

▲

Firm’s name (or
yours if self-employed),
address, and ZIP code

Title
Date

▲

Paid
Preparer’s
Use Only

Under penalties of perjury, I declare that I have examined this submission, including the accompanying documents, and, to the best of my knowledge and
belief, all of the facts contained herein are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which
preparer has any knowledge.

Preparer’s SSN or PTIN

Check if selfemployed
EIN

Phone no.

Form 8942 (6-2010)