Authorization for Signer of Llc

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                               FORM A                                                                                    APPLICATION CHECKLIST

      Read the VEGI Program Information, Administrative Rules and all instructions before filling in this form.
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      Please use this checklist to ensure that all required information and forms are submitted and your application is
      complete.
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      Date Application Submitted:
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      Company Name:
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 9 Contact Person:
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      Type of Application:
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 12                                                                                         Initial                Final

 13 Form B - Applicant Information
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 15 Form C - Applicant Data
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 17 Form D - Applicant Business Information
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 19 Form E - "But-For" Statement and Signatures
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 21 Form F - Guideline Responses
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 23 Form G - Authorization and Certifications
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 25 If Applying for Property Tax Stabilization:
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 27 Form H - Municipal Applicant Information
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 29 Form I - Municipal Certification
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 31
 32 Attachments:
 33 Letters of Support: (See Guideline 4; REQUIRED for Final Applications and some Initial Applications)

 34                              Regional Development Corporation

 35                              Regional Planning Commission

 36                              Municipality
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 38 Project Site Map (See Guideline 8; REQUIRED for Final Applications)
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 40 Letter Certifying Good Standing from Vermont Department of Taxes (REQUIRED - See Instructions)
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 42 Other
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 44 Other
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 46 Other
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 48 For Property Tax Stabilization Applications: Stabilization Agreement with Municipality or Letter from Municipality
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 50 Application Common Errors Checklist and Certification (REQUIRED - See instructions)
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Version 5.28.2008                                                  Form A - Application Checklist                                                Page 1
                      A                        B                   C                             D           E           F         G

                          FORM B                                               APPLICANT INFORMATION
 1                                                                                                               Column1

       Read the VEGI Program Information, Administrative Rules and all instructions before filling in this
 2                                                 form                                                          C

      Official Name of Business
 3                                                                                                               LLC
   Common Name (i.e. dba, if
 4 different from Line 3)                                                                                        LLP
 5 Mailing Address                                                                                               Other

 6    a. City/Town                                        b. State/ Province                                     Partnership

 7 a. Postal Code                                         b. Country                                             S

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   a. Telephone Number                                    b. Fax Number                                          Sole Proprietor
   Vermont Business Account
 9 Number                                                                                                        Non-Profit


 10   Federal Employer ID Number                                                                                 Not for Profit

    North American Industrial
    Classification System code
 11
    (6 Digits)                                                                                                   Undecided

      Form of Corporation
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 13   Fiscal Year End
      State of Incorporation
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      Type of Company/Project
 15                                                                                                              Column1

 16   If Vermont Division, Location of parent company                                                            Expansion of Vermont Company
      Physical Address/ Location of
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      proposed Project                                                                                           Expansion of Multi-state Division Already i
 18 Application Contact Person                                                                                   Moving a Multi-state Division to Vermont
 19 a. First Name                                         b. Last Name                                           Establishing a new Division of a Multi-state
 20 Title                                                                                                        Establishing a Completely New Business
      Address
 21

 22   a. City/Town                                        b. State/ Province
 23 a. Postal Code                                        b. Country
    Telephone Number and
 24 extension

 25   Mobile Number

 26   Fax Number

 27   Email Address




Version 5.28.2008                                               Form B - Applicant Information                                           Page 2
                       A               B            C                             D   E   F   G

 28 Application Signer's Information

 29   Signature 1

 30   a. First Name                        b. Last Name
 31   Title
 32   Address
 33   a. City/Town                         b. State/ Province
 34 a. Postal Code                         b. Country
    Telephone Number and
 35 extension
 36 Mobile Number
 37   Fax Number
 38   Email Address

 39   Signature 2

 40   a. First Name                        b. Last Name
 41   Title
      Address
 42

 43
      a. City/Town                         b. State/ Province

 44   a. Postal Code                       b. Country
    Telephone Number and
 45 extension
 46 Mobile Number

 47   Fax Number

 48   Email Address




Version 5.28.2008                                Form B - Applicant Information                   Page 3
                      A                B      C                             D   E   F   G




      Description of applicant's
      primary business activity:




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      Description of activity to be
      incented:




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      Eligible for Enhanced VEGI for
      Environmental Technology
      Companies
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      Activity Commencement Date
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      Relationship of multiple
      applicants



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Version 5.28.2008                          Form B - Applicant Information                   Page 4
                         H        I     J           K   L

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ansion of Vermont Company
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ansion of Multi-state Division Already in Vermont
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ng a Multi-state Division to Vermont
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               Division of a Multi-state Company in Vermont
blishing a new 19
blishing a Completely New Business
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               21

               22
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               24

               25

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              Version 5.28.2008                               Form B - Applicant Information   Page 5
        A           B              C                D                 E             F              G                H              I             J             K             L                M                N

 1    FORM C                                                                                 0

                             Read the VEGI Program Information, Administrative Rules and all instructions before filling in this form
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  3 NUMBER OF EMPLOYEES, ANNUALIZED                     PAYROLL, AND CAPITAL INVESTMENTS: AS OF ACTIVITY COMMENCEMENT DATE
  4 NUMBER OF EMPLOYEES:                                         ANNUALIZED PAYROLL:                                          CAPITAL INVESTMENTS TO DATE:
  5       TOTAL EMPLOYEES:            0                           TOTAL PAYROLL:                                           $0 TOTAL CAPITAL INVESTMENTS                             $0
  6       OTHER SUBTOTAL:             0                           OTHER SUBTOTAL:                                          $0 Machinery and equipment acquired
  7                Owners                                                  Owners                                              Machinery and equipment new
  8                Part-time/Seasonal                                      Part-time/Seasonal                                  Machinery and equipment used
  9       FULL-TIME SUBTOTAL:         0                           FULL-TIME SUBTOTAL:                                      $0 Plant and facility acquired
 10                Non-Qualifying                                          Non-Qualifying                                      Plant and facility built new
 11                Qualifying                                              Qualifying                                          Plant and facility renovations
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 13 NUMBER OF EMPLOYEES: ANNUAL HEADCOUNT AND ANNUAL                                     HEADCOUNT PROJECTIONS
 14                                             Year -3   Year -2   Year -1                      Year 0           Year 1         Year 2        Year 3        Year 4        Year 5
 15                                                                                                                                                                                       TOTALS           TOTALS
 16 TOTAL EMPLOYEES                                     0         0                      0                0                 0             0             0             0              0                0
 17 TOTAL ADDED EMPLOYEES:                                                                                                  0             0             0             0              0                0
 18        OTHER SUBTOTAL:                              0         0                      0                0                 0             0             0             0              0                0
 19                   Owners                                                                                                                                                                          0
 20                   Part-time/Seasonal                                                                                                                                                              0
 21        FULL-TIME SUBTOTAL:                          0         0                      0                0                 0             0             0             0              0                0
 22                   Non-Qualifying                                                                                                                                                                  0
 23        Total Qualifying                             0         0                      0                 0                0              0             0             0             0                0
 24                   Existing Qualifying
 25                   Job Targets (New Qualifying)                                                                                                                                                    0
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 27 PAYROLL: ANNUAL PAYROLL                   AND ANNUAL PAYROLL PROJECTIONS
 28                                               Year -3          Year -2       Year -1         Year 0           Year 1         Year 2        Year 3        Year 4        Year 5
 29                                                 0                0             0               0                0              0             0             0             0
 30 TOTAL PAYROLL:                                          $0            $0            $0                $0               $0             $0            $0            $0            $0                $0
 31          OTHER SUBTOTAL:                                $0            $0            $0                $0               $0             $0            $0            $0            $0                $0
 32                     Owners                                                                                                                                                                        $0
 33                     Part-time                                                                                                                                                                     $0
 34          FULL-TIME SUBTOTAL:                            $0            $0            $0                $0               $0             $0            $0            $0            $0                $0            $0
 35                     Non-Qualifying                                                                                                                                                                $0
 36          Total Qualifying                               $0            $0            $0                $0               $0             $0            $0            $0            $0                $0
 37                     Existing Qualifying                                                                                                                                                           $0
 38                     New Qualifying                                                                                                                                                                $0
 39                     Payroll Targets                                                                                                                                                               $0
 40 Average Annual Percent Increase
 41 Benefits Ratio
 42 CAPITAL INVESTMENTS: ANNUAL EXPENDITURE PROJECTIONS
 43                                                                                              Year 0           Year 1         Year 2        Year 3        Year 4        Year 5
 44                                                                                                0                0              0             0             0             0
 45 TOTAL CAPITAL INVESTMENTS:                                                                            $0               $0             $0            $0            $0            $0                0
 46 CAPITAL INVESTMENT TARGETS                                                                                             $0             $0            $0            $0            $0                0
 47   SUBTOTAL MACHINERY AND EQUIPMENT:                                                                   $0               $0             $0            $0            $0            $0                0
 48                 Machinery and Equipment - Acquired
 49                 Machinery and Equipment - Purchased New                                                                                                                                           0
 50                                          Percentage Purchased from within VT
 51                 Machinery and Equipment - Purchased Used
 52                                          Percentage Purchased from within VT
 53   SUBTOTAL PLANT AND FACILITIES:                                                                      $0               $0             $0            $0            $0            $0                0
 54                 Plant and Facilities - Acquired                                                                                                                                                   0
 55                 Plant and Facilities - Built New                                                                                                                                                  0
 56                                          Percentage Purchased from within VT
 57                 Plant and Facilities - Renovations                                                                                                                                                0
 58                                          Percentage Purchased from within VT
 59   LAND                                                                                                                                                                                            0
 60
 61 CAPITAL INVESTMENTS: TYPE OF FACILITY
 62                                                                                                               Year 1         Year 2        Year 3        Year 4        Year 5
 63                                                                                                                 0              0             0             0             0
 64 TOTAL PLANT AND FACILITY INVESTMENT:                                                                                    $0          $0            $0            $0               $0               0
 65 PERCENTAGE BY TYPE OF USE:                                                                                             0%          0%            0%            0%               0%
 66                                                              Industrial:
 67                                                              Commercial/Non-Office:
 68                                                              Office:
 69                                                              Warehouse/shipping-receiving:
 70                                                              Other:
 71
 72 BREAKDOWN OF           QUALIFYING JOB CREATION
 73                                                                                                               Year 1         Year 2        Year 3        Year 4        Year 5
 74 JOB CATEGORY                                                               AVG ANNUAL SAL/ WAGE                 0              0             0             0             0
 75                                                                                                                                                                                                   0
 76                                                                                                                                                                                                   0
 77                                                                                                                                                                                                   0
 78                                                                                                                                                                                                   0
 79                                                                                                                                                                                                   0
 80                                                                                                                                                                                                   0
 81                                                                                                                                                                                                   0
 82                                                                                                                                                                                                   0             0
 83                                                                                      TOTALS                      0             0             0             0             0                        0
 84                                                                 ESTIMATED HIRING BY QUARTER
 85                                                                                          $0
 86
 87                                                                                                               Year 1         Year 2        Year 3        Year 4        Year 5
 88                                                                                                                 0              0             0             0             0
 89                                                                                                                        $0             $0            $0            $0            $0                $0
 90                                                                                                                        $0             $0            $0            $0            $0                $0
 91                                                                                                                        $0             $0            $0            $0            $0                $0
 92                                                                                                                        $0             $0            $0            $0            $0                $0
 93                                                                                                                        $0             $0            $0            $0            $0                $0
 94                                                                                                                        $0             $0            $0            $0            $0                $0
 95                                                                                                                        $0             $0            $0            $0            $0                $0
 96                                                                                                                        $0             $0            $0            $0            $0                $0
 97                                                                                          TOTALS                        $0             $0            $0            $0            $0                $0            $0
 98                                                                                                                                                                                         #DIV/0!                 $0
 99                                                                                                                                                                                                                 $0




Version 5.28.2008                                                                                              Form C - Project Data                                                                                     Page 6
                    A                    B                            C                                                      D

 1      FORM D                 BUSINESS INFORMATION NARRATIVE
                              BUSINESS INFORMATION NARRATIVE                                                                                     0
                                   Read the VEGI Program Information, Administrative Rules and all instructions before filling in this form
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      Brief History of the Company:
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      Describe the project that is the subject of this application:
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      If applicant is part of a larger corporation, describe the corporate structure:
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      Multiple applicant entity information:




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Version 5.28.2008                                                           Form D - Biz Info Narrative                                       Page 7
                A                         B                       C                         D                         E               F                                G                    H   I

      FORM E                                               BUT FOR STATEMENT                                                                                                            0
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                            Read the VEGI Program Information, Administrative Rules and all instructions before filling in this form
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         I declare that the statements included herein regarding whether this activity would occur or would not occur, or would occur in a
             significantly different and significantly less desirable manner, are true, correct and complete to the best of my knowledge.
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      Signature 1: Signature of President or CEO:
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 8                  Signature:

 9            Typed Name:

 10                     Title:                                         Date:
               ____ I certify that I am the President or CEO of the applicant company or that I am an officer of, and have the authority to sign on behalf of, the applicant company.
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      Signature 2: Signature of Top Company Representative in Vermont or Second Vermont Company Officer:
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 13                 Signature:

 14           Typed Name:

 15                     Title:                                         Date:

                           ____ I certify that I am a officer or employee of the applicant company and that I have the authority to sign on behalf of, the applicant company.
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      PRINT OUT FORM E FOR OFFICERS TO SIGN AND MAIL IN WITH HARD COPY OF APPLICATION

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Version 5.28.2008                                                                               Form E - But For Statement                                                                      Page 8
         J          K   L   M


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Version 5.28.2008               Form E - But For Statement   Page 9
                A                            B              C                              D                          E
      FORM F                                                            GUIDELINE RESPONSES
     Read the VEGI Program Information, Administrative Rules and all instructions before

1    filling in this form                                                                                         `
     GUIDELINE 1: The enterprise should create new full-time jobs to be filled by individuals who are Vermont
     residents. The new jobs shall not include jobs or employees transferred from an existing business in the
     state or replacements for vacant or terminated positions in the applicant’s business. The new jobs include
     those that exceed the applicant’s average annual employment level in Vermont during the two preceding
     fiscal years. The enterprise should provide opportunities that increase income, reduce unemployment, and
     reduce facility vacancy rates. Preference should be given to projects that enhance economic activity in
     areas of the state with the highest levels of unemployment and the lowest levels of economic activity.


2
3 Efforts to Hire Vermont residents:




4
5 Current Vermont Resident Percentage:
6 Projection Vermont Resident Percentage:
7 Other Locations, Divisions, etc?
8 Name, Address of Other Locations, Divisions, etc.:                   Number of FT Employees:
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14 Efforts to Increase Incomes and Decrease Unemployment:




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16 Efforts to Utilize Existing Facilities:




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              A                       B                        C                                  D                E
   Guideline 2: The new jobs should make a net positive contribution to employment in the area, and meet or
   exceed the prevailing compensation level, including wages and benefits, for the particular employment
   sector. The new jobs should offer opportunities for advancement and professional growth consistent with
18 the employment sector.
19                                                  Current Employment:
                             Number as of Date of    Starting Annual Salary/
         Job Category                                                                Average Annual Salary/ Wage
20                              Application                   Wage

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33                                                       New Jobs:
                              New Jobs Created
                                                     Starting Annual Salary/
         Job Category        During Five Years of                                    Average Annual Salary/ Wage
                                                              Wage
34                                 Project
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46 Benefit                                                                            Percent Paid by Employer
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58        a. Hourly Employee Benefits Ratio                           b. Salaried Employee Benefits Ratio

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60 Description of the opportunities available for employee advancement and professional growth:




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               A                      B                      C                                D                     E

        Guideline 3: The enterprise should create positive fiscal impacts on the state, the host municipality and
                         region as projected by the cost-benefit model applied by the Council.
62




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     Guideline 4: The enterprise should be welcomed by the host municipality, and should conform to all
     appropriate town and regional plans and to all permit and approval requirements.
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     Guideline 5: The enterprise should protect or improve Vermont’s natural, historical, and cultural resources,
66
     and enhance Vermont’s historic settlement patterns.

67 Impact on Natural Resources:




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69 Impact on Historical Resources:




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71 Impact on Cultural Resources:




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73 Impact on Historic Settlement Patterns:




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             A                         B                     C                                     D                      E
75 Guideline 6. It is desirable for the enterprise to make use of Vermont’s resources.
76 Vermont Natural Resources Utilized:




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78              Name of Vermont Company                Type of Relationship                      Value
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      Guideline 7. It is desirable for the enterprise to strengthen the quality of life in the host municipality and to
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      foster cooperation within the region.
102                       Name of Organization or Group                                    Value of Donation
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115 Volunteer Policies:




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117 Environmental Impact:




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119 Other:




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                A                      B                       C                                 D                      E
    Guideline 8: It is desirable for the enterprise to use existing infrastructure or to locate in an existing
121 downtown redevelopment project.
122 Description of Infrastructure:




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124 Location Description:




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      Guideline 9. If the enterprise proposes to expand within a limited local market, then the enterprise should not
      be given an unfair competitive advantage over other Vermont businesses in the same or similar line of
      business and in the same limited local market as a result of the economic incentive granted.
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127 Market Description:




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129 Competition:




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131 Impact on Vermont Businesses:




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                     A                             B                        C                           D
      FORM G                    AUTHORIZATION AND CERTIFICATIONS
      Read the VEGI Program Information, Administrative Rules and all instructions before
  1   filling in this form
      Authorization to Share Information: The Commissioner of Taxes and the Vermont Economic
      Progress Council are hereby authorized to share information for purposes of determining the
      eligibility of the applicant to receive incentives listed in this application, and any future incentives
  2   claimed by the applicant or received by the applicant.
      Certification of Intent: I declare under penalties of perjury that this application and all documents
      attached in support of this application are true, correct, and complete to the best of my knowledge.
  3
      Certification of Understanding: I have read the Administrative Rules and Statute for this program
      and understand the following: 1) That the incentive authorized can only be earned if base payroll is
      maintained or increased and targets are met; 2) That installments of earned incentives can be
      forfeited if employment or payroll levels drop below targets; 3) That the total amount of incentive
      authorized is in part based on the capital investment targets included in this application and that if
      the total capital investment target is not met the incentive amount may be decreased proportionate
      to the percent of the capital investment that was not completed, including possible recapture, if
      required; 4) That if the applicant company drops employment or payroll below 10% of the
      employment or payroll levels at the time of application, 100% of the incentives paid will be
      recaptured; and 5) That if an authorization amendment is required after a Final Application
      authorization and the amendment is due to an applicant error, the authorized incentive amount will
      not be increased.
  4
      Certification Regarding Employment: I certify that in accordance with Title 32, Section 5930a(c)(1),
      the new jobs to be created by the project included in this application do not include any jobs or
      employees transferred from another existing operation in Vermont that is a division or subsidiary
      of any kind of the applicant company and that the new jobs are not replacements for positions
      within the applicant's business that were vacated or terminated within the past two years.
  5
      Certification of Good Standing: I certify that the applicant company is in good standing with the
      State of Vermont as defined by 32 VSA Section 3113(g). (Attach Letter of Good Standing from Vermont
  6   Department of Taxes to application.)

  7
      Signature 1: Signature of President or CEO:

  8                        Signature:

  9                      Typed Name:

 10                              Title:                           Date:
      ____ I certify that I am the President or CEO of the applicant company or that I am an officer of, and have the
      authority to sign on behalf of, the applicant company.
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      Signature 2: Signature of Top Company Representative in Vermont or Second Vermont
 12   Company Officer:

 13                        Signature:

 14                      Typed Name:

 15                              Title:                            Date:
      ____ I certify that I am a officer or employee of the applicant company and that I have the authority to sign on
      behalf of, the applicant company.
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      0
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      PRINT OUT FORM G FOR OFFICERS TO SIGN AND MAIL IN SIGNED FORM WITH
      HARD COPY OF APPLICATION.
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Version 5.28.2008                                                                  Form G - Auth And Cert                Page 15
                A                          B                     C                   D              E

      FORM H          PROPERTY TAX STABILIZATION -
      MUNICIPAL INFORMATION
      Read the VEGI Program Information, Administrative Rules and all instructions
      before filling in this form
 1

 2    MUNICIPALITY:
 3                             First Name:                                  Last Name:

 4                             Title:
 5                             Mailing Address:
 6                             City/Town:                                   State:
 7                             Postal Code:
 8    Contact Person           Telephone Number:
 9                             Mobile Number:
 10                            Fax Number:
 11                        Email Address:
 12   Property Tax Stabilization Information
 13
 14   SPAN for subject property
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      Listed address of subject property
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      Listed Owner of Subject Property
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 20   Current assessed value of subject property (prior to project):
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 22   Estimated assessed value of subject property upon completion of project:
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 24 Date Stabilization Will Begin:
 25 Date Stabilization was Approved by the Municipality:
 26 Current Tax Rate:
 27   Municipal:
 28   State Education:
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Version 5.28.2008                                                      Form H- Prop Tax Muni Info       Page 16
                    A                  B                       C           D              E
 1       FORM I                                  MUNICIPAL OFFICER CERTIFICATIONS
 2       Read the VEGI Guidebook and instructions for all forms before filling in this form.
     Certification of Intent: I declare under penalties of perjury that the
     information contained on Form H of this application provided by the
     municipality and all documents attached in support of this application that
     have been provided by the municipality are true, correct, and complete to
 3
     the best of my knowledge.
     Certification of Understanding: I have read the Administrative Rules of this
     program and understand the program requirements and responsibilities
     for the municipality and the implications of not adhering to the program
     requirements.
 4
 5   Signature of Municipal Officer:

 6                      Signature:

 7              Typed Name:

 8                          Title:                                 Date:
 9                              0
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Version 5.28.2008                          Form I- Muni Cert                             Page 17

				
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Description: Authorization for Signer of Llc document sample