Voluntary Remediation Program
Louisiana Department for Environmental Quality
brownfields investor tax credit application form
This is a tax credit application for (select one):Voluntary Remedial Investigation
Voluntary Remedial Action
I. Applicant Information
Section A: Applicant Information
DEQ Agency Interest (AI) Number (if one exist):
Site Name (NOTE: Must match site name on VRP application):
Name/Company Name:
Mailing Address:
City: / State: / Zip Code:
Contact Person:
Phone Number: / Fax Number:
E-mail Address:
Section B: Applicant Taxpayer ID
Applicant Taxpayer ID Number:
II. Applicant Eligibility Information
I (applicant) certify that I (applicant) am not an ineligible participant with regard to bankruptcy or loans made or guaranteed by the state as provided in R.S. 47:6021.H. / Yes / No
Section A: Answer the following questions by checking the appropriate answer:
Were you a generator who generated a hazardous substance or hazardous waste that was disposed of or discharged at the site? / Yes / No
Were you a transporter who disposed of or discharged a hazardous substance or hazardous waste at the site? / Yes / No
Were you a disposer who disposed of or discharged a hazardous substance or hazardous waste at the site? / Yes / No
Did you contract with someone for transportation or disposal at the site? / Yes / No
Section B: If you are or were an owner or operator of the site subsequent to the disposal of hazardous waste, answer the following questions by checking the appropriate answer:
Were you engaged in the business of generating, transporting, storing, treating, or disposing of a hazardous substance or hazardous waste on or in the sit, or knowingly permitted others engaged in such business on the property? / Yes / No
Did you knowingly permit any person to make regular use of the property for disposal of waste? / Yes / No
Did you knowingly permit any person to use the site for disposal of a hazardous substance? / Yes / No
Did you know or should you have reasonably known that a hazardous substance was located in or on the site at the time right, title, or interest in the site was first acquired by the person and engaged in conduct associating that person with the discharge or disposal? / Yes / No
Did you take action that significantly contributed to the discharge or disposal after that person knew or reasonably should have known that a hazardous substance was located in or on the site? / Yes / No
if you answered yes to any of the above questions in part ii, section b, you are not eligible for the tax credit.
III. Site Eligibility Information
Are there permitted hazardous waste units on the site? / Yes / No
Has the site been proposed for listing on the National Priorities List (NPL) by the United States Environmental Protection Agency (EPA)? / Yes / No
Has the site been listed on the National Priorities List (NPL) by EPA? / Yes / No
Are there any pending federal environmental enforcement actions associated with the site? / Yes / No
If yes, please explain:
Yes / No
if you answered yes to any of the above questions in part iii, the site may not be eligible for the tax credit.
IV. Statement of Projected Economic Benefits to the Applicable Community
Estimated Total Projected Eligible Expenditures for this Investigation or Remedial Action:
List the number of permanent full time jobs in Louisiana:
Current Jobs: / Annual Salaries:
Proposed Jobs: / Annual Salaries:
List the number part time jobs in Louisiana:
Current Jobs: / Annual Salaries:
Proposed Jobs: / Annual Salaries:
List the projected number of temporary jobs related to the remedial investigation in Louisiana:
Current Jobs: / Annual Salaries:
Proposed Jobs: / Annual Salaries:
Describe use of the property after remedial action:
List the capital investment post remediation, including but not limited to additional permanent jobs, construction jobs, buildings, equipment, labor, etc.
V. Certification
All applicants must certify the following with their signature below:
I certify that all the information I have provided in the Brownfields Investor Tax Credit Application Form is true and correct to the best of my information, knowledge, and belief. I understand and agree that I am obligated to update and notify this application if I learn that information that I have provided is misleading or no longer correct.
Applicant Signature: ______/ Date: ______
Form_5294_r05 page 2 of 2
5/28/2008