Indiana Department of Revenue SCHEDULE LIC State Form 21926 (R6/8-10) 814 Enterprise Zone Loan Interest Tax Credit For Tax Year Ending: Month_________ Year _______ (Enclose completed schedule with annual state tax liability return.) Enclosure Sequence No. 28 Section A - Taxpayer Information Name of Taxpayer (lender) Social Security or Federal Identification Number Street Address County City or Town, State, and ZIP Code Taxpayer's Telephone Number ( ) Section B - Qualified Loan Information (attach list of all borrowers) Section B continued on reverse side. Name of Borrower (A) Borrower's Social Security or Federal Identification Number Street Address Borrower's Telephone Number City or Town, State, and ZIP Code Use of Loan (check one): Date of Loan Origination: Location Name of Borrower's Enterprise Zone Business Personal Section C - Report of Qualified Loans to Businesses by Enterprise Zone Locations Summarize the number of qualified loans to businesses in each enterprise zone and the amount of interest received during the taxable year. Enterprise Zone (a) Number (b) Interest of Loans Income Bedford $ Bloomington $ Connersville $ East Chicago $ Elkhart $ Evansville $ Ft. Harrison $ Ft. Wayne $ Frankfort $ Gary $ Grissom Aeroplex $ Hammond $ Indiana Army Ammunition Plant $ Indianapolis $ Subtotal $ Enterprise Zone 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 (c) Number (d) Interest of Loans Income Jeffersonville $ Kokomo $ Lafayette $ La Porte $ Marion $ Michigan City $ Mitchell $ New Albany $ Portage $ Richmond $ Salem $ South Bend $ Terre Haute $ Vincennes $ Subtotal $ 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 Section D - Credit for Qualified Loans for the Taxable Year 1. Grand total of all qualified loans to businesses listed in Section C, columns (a) and (c) ............................ 1 $ 00 2 Total amount of loan interest income received from qualified loans listed in Section C, columns (b) and (d) . 2 $ 00 3. Amount of loan interest income received from other qualified nonbusiness loans made for home improvements within all enterprise zones ................................................................................................... 3 $ 00 4. Total Loan Interest Credit - add amounts on lines 2 and 3; multiply result by 5 percent (.05) .................... 4 $ 00 5. Indicate for which tax type you are applying this credit. Enter net amount of tax you are offsetting: a Adjusted Gross Income Tax b Insurance Premium Tax c Financial Institutions Tax ....... 5 $ 00 The tax offset may not exceed the amount of available credit from line 4. Carry amount on line 5 to other credit line of your return. 6. Unused amount of credit available for carryover - subtract line 5 from line 4 and complete Section E ...... 6 $ 00  11210111594 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 Schedule LIC Section B - Qualified Loan Information Continued (Attach additional sheets if necessary.) Name of Borrower (B) Borrower's Social Security or Federal Identification Number Street Address Borrower's Telephone Number City or Town, State, and ZIP Code Use of Loan (Business or Personal): Date of Loan Origination: Location Name of Borrower's Enterprise Zone Name of Borrower (C) Borrower's Social Security or Federal Identification Number Street Address Borrower's Telephone Number City or Town, State, and ZIP Code Use of Loan (Business or Personal): Date of Loan Origination: Location Name of Borrower's Enterprise Zone Name of Borrower (D) Borrower's Social Security or Federal Identification Number Street Address Borrower's Telephone Number City or Town, State, and ZIP Code Use of Loan (Business or Personal): Date of Loan Origination: Location Name of Borrower's Enterprise Zone Section E - Enterprise Zone Interest Credit Carryover (814) Enter the initial tax period in which the Enterprise Zone Loan Interest Credit was claimed. Enter the remaining unused amount of credit from Section D, line 6. Initial Tax Year Ending: Month ________________ Year_________ Enterprise Zone Loan Interest Credit Available for Carryforward from Section D, Line 6: $_______________________________ Show how the unused credit is applied during the carryover period. Unused Credit (column 5) is to be placed on your return for the next tax year. (1) Credit Carryforward (2) Total Amount of Tax (3) Type of Tax Liability Reduced (4) (5) Amount Applied Unused Credit 1st Following Tax Year 2nd Following Tax Year 3rd Following Tax Year 4th Following Tax Year 5th Following Tax Year 6th Following Tax Year 7th Following Tax Year 8th Following Tax Year 9th Following Tax Year 10th Following Tax Year Section F - Signature I certify I have examined this schedule and, to the best of my knowledge and belief, the information contained in this schedule is true, correct, and complete. Signature of Taxpayer: Title: Date Signed:  11210121594 American LegalNet, Inc. www.FormsWorkFlow.com Enterprise Zone LIC Instructions Indiana Code (IC) 6-3.1-7-2 provides that a taxpayer who is in good standing with the Indiana Economic Development Corporation is entitled to a state income tax credit of 5% of the interest income received from qualified loans made during the year. To qualify, the loan proceeds must be for purposes directly related to businesses located in an enterprise zone or for improvements increasing the assessed value of real property located in an enterprise zone.* A “qualified loan” also means a loan made to an individual or business that uses the loan proceeds toward the rehabilitation, repair, or improvement of a residence within an enterprise zone. *An enterprise zone created under IC 5-28-15 or an airport development zone (code # 802) designated under IC 8-22-3.5-14. Maps of enterprise zones and addresses can be found on the Web at www.in.gov/dor/3619.htm Section B – Qualified Loan Information Enter the following information for each qualified loan, or provide a combined listing of borrowers within every enterprise zone. Attach additional sheets as necessary (type or print): 1) Enter the borrower’s name and location address within the enterprise zone. 2) Enter the borrower’s Social Security or federal identification number. 3) Enter the borrower’s telephone number. 4) Indicate the purpose of the loan (business or personal home improvement) and the date of loan origination. 5) Enter the name of the borrower’s enterprise zone location. Section C – Report of Qualified Loans to Businesses by Enterprise Zone Locations Who may file for this credit? For the purposes of eligibility, for the Loan Interest Credit, a taxpayer in good standing is defined as an entity conducting business operations within an enterprise zone that 1) Receives interest on a qualified loan made during the tax year; 2) Pays the registration fee charged to zone businesses under IC 5-28-15-5; 3) Provides the assistance to urban enterprise associations required from zone businesses under IC 5-28-15-5(b); and 4) Complies with any requirements adopted by the board of the Indiana Economic Development Corporation for taxpayers claiming the Enterprise Zone Loan Interest Credit. Note: If the taxpayer is located outside an enterprise zone, the taxpayer is not required to reinvest its incentives within the enterprise zone, other than complying with (2) and (3) above. How often can I claim a credit? A claim for credit is filed annually for each qualified loan or in combination with all qualified loans made during the taxable year. Section A – Taxpayer Information 1) 2) 3) 4) Type or print lender’s name and address. Enter lender’s Social Security or federal ID number. Enter Indiana county or O.O.S. (out-of-state). Enter telephone number. Summarize the number of qualified loans made during the taxable year according to the enterprise zone in which the loan proceeds are used by the business borrower(s) (listed in Section B). Enter the total amount of interest income received from qualified loans to businesses during the taxable year attributed to the enterprise zone location of the borrower(s), columns (a) and (c). For purposes of the loan interest credit, interest includes service charges, time-price differentials, and all other charges for the use of money. Interest received from loans and lines of credit existing at the time an enterprise zone was designated qualify for the credit if the proceeds are used for a qualified purpose. Interest from mortgage loans to acquire property does not qualify unless the property is used for business purposes (including renting or leasing). If the proceeds of a loan are used to both acquire and improve real property and the acquisition is not for a business purpose, only that portion of the interest attributable to the improvement of the property would qualify for the loan interest credit. If the loan proceeds are used to acquire business property which is subsequently removed from an enterprise zone, only the interest received while the property was used for a business purpose within the enterprise zone would qualify for the credit. Section D – Credit for Qualified Loans for the Taxable Year Line 1. Enter the grand total of all qualified loans to businesses listed in Section C, columns (a) and (c). Line 2. Enter the amount of loan interest income received from businesses during the taxable year from qualified loans listed in Section C, columns (b) and (d). American LegalNet, Inc. www.FormsWorkFlow.com Enterprise Zone LIC Instructions, continued Line 3. Enter the total other loan interest income received from nonbusiness loans made for the purposes of rehabilitation, repair, or improvement of a residence or for improvements that increase the assessed value of real property located in any enterprise zone. Line 4. Add the amount of business and nonbusiness interest income and multiply the result by 5%. Line 5. Indicate the state tax liability you wish to offset by checking the appropriate tax type box and by entering the net amount of your state tax liability. Note: The net amount of tax entered on line 5 must be reduced by all other applicable tax liability credits and may not be greater than the amount on line 4. Carry the net amount of credit to be used to your tax type return. Line 6. Subtract line 5 from line 4. The result may not be less than zero. If it's greater than zero, carry the excess unused amount of credit to Section E. Section E – Enterprise Zone Loan Interest Carryover Complete this section whenever there is a carryover of unused loan interest credit. The amount of credit carryover from a taxable year shall be reduced to the extent that the carryover is used by the taxpayer to obtain credit against allowable state tax liabilities for any subsequent taxable year. Carryover is allowed up to 10 years following the date on which a qualified loan credit is claimed but not beyond the phase-out period that terminates the enterprise zone from which a qualified loan had originated. Enter in each column the applicable date or amounts for every succeeding taxable year in which a credit carryover is used. Section F – Signature The taxpayer or an authorized agent must sign this schedule. What if I do not use all of my credit? Any unused credit may be carried over to the next eligible tax return to be filed up to 10 years from the date of the loan until all credit has been used or the enterprise zone terminates. Note: A taxpayer is not entitled to a carryback or refund of any unused credit. The statute does allow the taxpayer to carry forward any unused credit. What if I am an entity exempt from adjusted gross income tax? Entities exempt from adjusted gross income tax under IC 6-3-2-2.8(2) may “pass through” the credit to shareholders, partners, beneficiaries, or members of the pass-through entity. A pass-through entity is an S corporation, partnership, trust, limited liability company, or limited liability partnership. Each member’s tax credit is calculated by multiplying the total credit available by the percentage of the entity’s distributive income to which the shareholder, partner, beneficiary, or member is entitled. The pro rata share of the calculated credit is reported by the entity on each unit-holder’s Schedule IN K-1. A copy of Schedule LIC or IN K-1 must be enclosed with the return to claim your share of the credit. Whom do I contact if I have questions about the Enterprise Zone Loan Interest Credit? Questions concerning enterprise zone income tax provisions should be directed to: Indiana Department of Revenue Returns Processing Center Corporate Income Tax Section 100 N. Senate Avenue Indianapolis, IN 46204-2253 (317) 233-4015 Web address: www.in.gov/dor/ For questions concerning other provisions related to enterprise zones and current locations within the designated cities, contact: Where can I claim this credit? The Loan Interest Credit can be applied as a credit against the taxpayer’s adjusted gross income tax (IC 6-3-1 through 6-3-7), insurance premium tax (IC 27-1-18-2), and financial institution tax (IC 6-5.5). A copy of Schedule LIC must be enclosed with the return; otherwise, the credit will be disallowed. The credit amount calculated on the LIC is to be taken as a credit against your tax liability on the return in the order listed above after first applying other credits allowed under IC 6-3.1-1-2. Indiana Economic Development Corporation One North Capitol, Suite 700 Indianapolis, IN 46204 (317) 232-8800 Web address: www.iedc.in.gov/ Refer to Income Tax Information Bulletin #66 for additional information. Please see the instructions for your tax return to determine where the credit should be entered on the various tax forms. American LegalNet, Inc. www.FormsWorkFlow.com