HomeMy WebLinkAboutIEDA - Business Financial Assistance Application (signature page only) - 11/25/2019SECTION H
Certification & Release of Information
1. Are there any judgments or court actions completed or pending against the applicant entity, or any current or
prospective officer, principal, director, or owner? ❑ Yes ® No
2. Has any current or prospective officer, principal, director, or owner been accused or convicted of any wrongdoing or
crime, other than a simple misdemeanor? ❑ Yes ►! No
3. Have there been any current or past bankruptcies on the part of the applicant entity (or predecessor entities), or on
the part of any current (or prospective) officer, principal, owner or in any business dealings of current (or
prospective) officers, principals, or owners of the applicant entity? ❑ Yes ® No
4. In the last five years have there been, or are there currently any investigations of potential violations of public
health, safety (including workplace safety) or environmental laws by the applicant entity, or any current or
prospective officer, principal, director, or owner? 0 Yes ►1 No
5. In the last five years have there been, or are there currently any violations of antitrust laws by the applicant entity,
or any current or prospective officer, principal, director, or owner? 0 Yes ® No
6. If yes to any of the above, please provide additional explanation:
I hereby give permission to the Iowa Economic Development Authority (IEDA) to research the Business' history, make credit checks,
contact the Business' financial institutions, insurance carriers, and perform other related activities necessary for reasonable
evaluation of this application. 1 also hereby authorize the Iowa Department of Revenue to provide to IEDA state tax information
pertinent to the Business' state income tax, sales and use tax, and state tax credits claimed.
I understand that all information submitted to IEDA related to this application is subject to Iowa's Open Record Law (Iowa Code,
Chapter 22), unless specifically marked as confidential section.
I understand that IEDA reserves the right to negotiate the financial assistance.
I understand this application is subject to final approval by IEDA and the Project may not be initiated until final approval is secured.
Furthermore, I am aware that funds will not be disbursed until a contract has been executed and the appropriate terms have been
met.
I understand that upon execution of the contract and prior to the issuance of a tax credit number or the disbursement of Award
Funds, a recipient shall pay IEDA a one-time compliance cost fee in the amount of $500. In addition, if tax benefits are greater than
$100,000, the Recipient shall remit to IEDA a compliance cost fee 0.5% of the value of the Tax Incentives claimed pursuant to the
contract. The fee will be due and payable upon filing the Recipient's annual tax return for each tax year in which tax credits are
claimed under the contract.
I hereby certify that all representations, warranties, or statements made or furnished to IEDA in connection with this application are
true and correct in all material respect. I understand that it is a criminal violation under Iowa law to engage in deception and
knowingly make, or cause to be made, directly or indirectly, a false statement in writing for the purpose of procuring economic
development assistance from a state agency or subdivision.
For the Business:
For the Sponsor(s):
Signature
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Name and itle (typed or printed) Name and Title (typed or printed)
S_1
Date
IEDA will not provide assistance in situations where it is determined that any representation, warranty, or statement made
in connection with this application is incorrect, false, misleading or erroneous in any material respect. If assistance has
already been provided prior to discovery of the incorrect, false, or misleading representation, IEDA may initiate legal action
to recover incentives and assistance awarded to the Business.