Eligible Business Corporation
Freedom of Information and Protection of Privacy Act (FIPPA) The information collected on this form is collected under the authority of the Small Business
Venture Capital Act, RSBC 1996 c. 429 (Act) and is subject to the provisions of the FIPPA. The personal information will be used for the administration of
the Act and the issuance of tax credits.
For more information regarding this form and the FIPPA please contact the Investment Capital Branch, Box 9800 Stn Prov Govt, Victoria, BC V8W 9W1
Full Name of the Eligible Business Corporation (EBC)
THIS ANNUAL RETURN IS FOR THE FISCAL YEAR THAT ENDED ON (dd/mm/yy)
For the period covered by this Annual Return:
Did the EBC make any significant changes to its eligible activity? (If “yes”, provide details).
Did the EBC acquire, cancel, redeem or transfer, except for those permitted under Regulation 3.1, any
shares and/or convertible rights held by an eligible investor? (If “yes”, provide details).
Have any eligible investors received any dividends from the EBC? (If “yes”, provide details).
Please indicate the following:
Number of employees at financial year end * (see page 2)
Percentage of salaries/wages paid to employees reporting to work in B.C.** (see page 2)
Percentage of assets and expenses in the qualifying activity (see page 2)
Percentage of assets located outside B.C.
Pursuant to Section 28.97 of the Act, copies of the following documents must be attached to the EBC’s Annual Return:
EBC Central Securities Register
EBC Financial Statements (financial statements must be prepared by a CPA, or other person licensed or registered with
an accounting association. EBCs that have raised $750,000 or more in equity capital and/or convertible right, must submit
statements prepared under a Review Engagement; EBCs that have raised less than $750,000 in equity capital and/or
convertible right can submit statements prepared under a Notice-to-Reader).
Annual Report filed with the Registrar of Companies
Convertible Right Agreement(s), if applicable
List of convertible right investors, if applicable
• The EBC has not used any income from tax credit supported equity capital or convertible rights, directly or indirectly, for
any purposes prohibited by Section 28.93 of the Act;
• All Regulation 14 events have been reported to the Administrator or Designate.
I am a Director or Officer of the eligible business corporation duly authorized to execute this Annual Return and a) have read
Sections 26 and 35 of the Small Business Venture Capital Act and understand that it is an offence and that it may expose me to
personal liability to make a false or misleading statement in this Annual Return; and b) to the best of my knowledge, all statements
made and information provided in this Annual Return and attachments are true, correct and complete.
(Sign on printed copy)
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