County of Henry
Enterprise Zone Program
Machinery & Tools Investment Plan/IDA Grant Form
Business Information
(Please Type or Print)
Name of Business:
Phone:
Fax:
Address:
City/State/Zip:
Project Location: (Tax Map Designation and Road or Street Name, or E-911 Structure Address if Known)
NAICS Code(s):
Zoning Code(s):
Contact Person:
Phone:
Fax:
Machinery & Tools Tax Information
Existing Machinery & Tools:
FIN#:______________________________________
Tax Account #:______________________________
_____Year Assessment: ___________________ and
Tax:_______________________
Attach copy of CURRENT tax bill
For Office Use Only:
Revised Machinery & Tools:
FIN#:______________________________________
Tax Account #:______________________________
_____Year Assessment: ____________________and
Tax:________________________
Filer's Statement - I hereby declare that, to the best of my knowledge and belief, the information contained
in this form is true and accurate and that I am authorized to act on behalf of the business.
Date Submitted:____________________ Authorized Signature:_________________________________
Commissioner of the RevenueVerification of Machinery & Tools Assessment and Tax
Machinery & Tools information, assessment, and tax are correct:
Yes
No
Comments:
Date:_____________________ Commissioner of the Revenue:_________________________________
Treasurer/Central Accounting - Verification of Machinery & Tools IDA Tax Grant
Refund from this filing: Year 1__________________ Years 2-5__________________ per year
Comments:
Date:___________________________ Treasurer:_________________________________________
Please print name: _____________________________________________
Enterprise Zone Investment Plan/IDA Grant Form
Page 2
Machinery & Tools Investment Data
Give a brief description of the project which includes information on the following points:
* List New Machinery & Tools
Placed in Service in Year ________
Quantity
Add-A
Replaced-R
Original Cost
Per Item
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Total Costs: $_____________
* If not enough space provided attach typed list in same format and label as Exhibit "A"
* * List Machinery & Tools
Taken Out of Service in Year _______
Quantity
Year Placed
In Service
Original Cost
Per Item
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Total Costs: $______________
* * If not enough space provided attach typed list in same format and label as Exhibit "B"
Current Number of Jobs: ________ Jobs To Be Retained: _________ Jobs To Be Created: _________
For Office Use Only: Do Not Write Below This Line:
County Administrator Review
Meets overall goals and objectives:
Yes
No
Meets incentive guidelines & procedures
Yes
No
Comments:__________________________________________________
Date:________________________ County Administrator:__________________________________