Revised November, 2004 – Page 1 of 2
VERIFICATION OF MISSOURI EXPENDITURES – FILM PRODUCTION TAX CREDIT
PROGRAM (Section 135.750, RSMo)
1. TAXPAYER
First Name
Middle Name
Last Name
Address (Street, P.O. Box)
City
State
Zip Code
E-mail Address
Telephone No.
Facsimile No.
Name of the Film Production Company
To receive a tax credit under the Film Production Tax Credit program, the taxpayer must complete this form and send to the department along with
the spreadsheet of detailed cost accounting supported by proof of purchases and proof of payments.
Return to: Department of Economic Development, Division of Business Development and Trade, Business Finance, 301 West High Street,
Room 720, P.O. Box 118, Jefferson City, MO 65102
Address (Street, P.O. Box)
City
State
Zip Code
Telephone No.
Address (Street, P.O Box)
Address (Street, P.O. Box)
Actual number of employees in Missouri during the project:
Business Size in Annual Sales:
□ $0 - $250,000 □ $250,000 - $500,000 □ $500,000 - $ 1 M □ $1 M - $ 5 M □ $ 5 M - $ 10 M □ $ 10 M & over
Name
Social Security No.
% Ownership
%
%
%
%
%
Is any other state or federal incentive programs being applied or utilized for this project?
□ Yes
□ No
If yes, please list all programs and corresponding amounts on a separate document.
Business entity for tax purposes:
Corporation
S- Corporation
Partnership
Individual
LLC
Other
Note: If a taxpayer is a Partnership, S-Corporation or other entity with a flow through tax treatment, identify the names, social
security numbers, and proportionate share of ownership of each beneficiary, partner, or shareholder on the last day of the tax
period. Aggregate proportionate shares or percent of total owners