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Form Last Revised 2/24/2014

Tax Incentives Application

Act to Promote the Transfer of Investors to Puerto Rico (Act 22 of January 17, 2012, as amended)

Case No. ________________________________

Instructions: Please respond to all of the questions in the space provided. If you are not a resident of Puerto Rico,

you may still apply if you intend to move to Puerto Rico within one (1) year. In such case, the tax incentives will be

subject to you becoming a resident of Puerto Rico within one (1) year after the grant has been approved.

A. Personal Information – Please fill-out the information requested.

Last Name:

_____________________________________________

First Name:

_____________________________________________

Middle Initial:

_____________________________________________

Social Security Number:

Applicant Email Address:

Telephone Number:

Fax Number:

Email Address:

_____________________________________________

Date of Birth: _____________________________________________

Place of Birth:

Current Nationality:

_____________________________________________

Home Address:

_____________________________________________

Mailing Address:

Married Status:

_____________________________________________

Single _____ Married: _____

Name of Spouse:

_____________________________________________

Social Security Number:

Spouse Email Address:

_____________________________________________

Application under Act 22-2012

2

Is the spouse requesting exemption under Act 22? _____Yes _____No

* This question is intended solely for information purposes. This application is only valid for the applicant

(one individual). The spouse will need to file a separate application under Act 22 in order to benefit from

this Act. A separate tax decree is granted for each individual.

B. Applicant’s Representative

Last Name:

_____________________________________________

First Name:

_____________________________________________

Middle Initial:

_____________________________________________

Home Address:

_____________________________________________

Mailing Address:

_____________________________________________

(if different)

_____________________________________________

Telephone Number:

Fax Number:

Web Page:

Email Address:

_____________________________________________

Residency History – Confirm if you have been a Puerto Rico resident during the last fifteen (15) years previous to

the effective date of Act. 22, which is January 17, 2012: _____Yes _____No

Please list the State(s) of the United States or Country (ies) in which you were a resident for tax purposes of the last

fifteen (15) fiscal years. If you were a resident for tax purposes in more than one jurisdiction for one particular year,

please list all relevant places of residence for such year.

Taxable Years

U.S. States or Country (include name)

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

Application under Act 22-2012

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C. Puerto Rico Residency

Current Resident of PR:

Yes _____ No: _____

Date of Residency:

_____________________________________________

If you are not a resident of Puerto Rico, please provide your current place of residency: ___________________

In your own handwriting, please transcribe the following statement in the space provided. (The individual must

transcribe the statement in his/her own handwriting)

Under penalty of fraud and tax evasion, I, [insert full name] ,

hereby swear that I was not a

Resident of Puerto Rico (as such term is defined in Section 1010.01 (a) (30) of Act 1 of 2011 as

amended, known as the Internal Revenue Code for a New Puerto Rico

*

) at any time from January 16,

1997 through January 16, 2012.

*

Note: The Internal Revenue Code for a New Puerto Rico can be found here:

http://www.hacienda.gobierno.pr/pdf/codigo_rentas_internas/Ley1_Codigo_Rentas_Internas.pdf.

___________________________________________________________________________________

D. Background and Professional Information

(1) What is your current profession? _____________________________________________________

(2) Please attach your curriculum vitae to the Application.

E. Financial Information, Investment, Real Estate & Business

(1) What is your approximate net worth?

a. Less than 10 million_____

b. 10 million – 50 million_____

c. 50 million – 100 million_____

d. More than 100 million_____

(2) Do you plan to transfer capital to financial institutions in Puerto Rico?

a. Yes_____

b. No_____

(3) If you answered Yes, please provide an estimate of the percentage of capital you will be transferring:

a. 0%-25%_____

b. 25% - 50%_____

c. 50% -75%_____

d. 75% - 100% _____

e. Other (please specify)______________________________________________________

(For example: I plan to transfer 25% now and 100% within the next 5 years)

Application under Act 22-2012

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(4) Have you bought or are you in the process of buying real estate in Puerto Rico?

a. Yes_____

b. No_____

c. If Yes, please indicate:

i. Location:_________________________________________________________

ii. Estimated value:___________________________________________________

(5) Would you be buying real estate in Puerto Rico during the next 12 months?

a. Yes_____

b. No_____

c. If Yes, please indicate:

i. Location: _________________________________________________________

ii. Estimated value:____________________________________________________

(6) Have you bought or are you in the process of leasing property in Puerto Rico?

a. Yes_____

b. No_____

c. If Yes, please indicate:

i. Location:_________________________________________________________

ii. Estimated property value:____________________________________________

iii. Estimated lease payment:____________________________________________

(7) Would you be leasing real estate in Puerto Rico during the next 12 months?

a. Yes_____

b. No_____

c. If Yes, please indicate:

i. Location:__________________________________________________________

ii. Estimated property value:_____________________________________________

iii. Estimated lease payment:____________________________________________

(8) At this moment, do you have a business established in Puerto Rico?

a. Yes_____

b. No_____- Please continue to Question (9)

c. If Yes, please indicate:

i. Name:____________________________________________________________

ii. Industry:__________________________________________________________

iii. Full-time employees:_________________________________________________

iv. Estimated yearly payroll for all employees:_______________________________

v. Location:__________________________________________________________

vi. Does this business have a tax exemption decree?

1. Yes_____

2. No_____

3. Is Yes, please indicate:________________________________________

vii. Did you establish this business as a result of your relocation?

1. Yes_____

2. No_____

(9) If you answered No to Question 8, would you consider establishing a new business in Puerto Rico?

a. Yes_____

b. No_____

Application under Act 22-2012

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c. If Yes, please indicate:

i. Full-time employees:_________________________________________________

ii. Industry:___________________________________________________________

iii. How much capital are you planning to invest?______________________________

(10) Will you be making other investments in Puerto Rico? Please explain in detail.

__________________________________________________________________________

(11) Do you have any children and what are their ages?_________________________________________

__________________________________________________________________________

(12) Tell us about yourself and any particular interests (for example: interested in music, charities, sports,

hobbies, etc.)

__________________________________________________________________________

*All questions in Section E are for informational purposes only. Questions 11 & 12 are aimed at your personal

interests in order to create a profile and extend invitations to you and your family for cultural and local events that

might be of interest to you.

F. Additional Information

(1) Have you ever committed a felony or misdemeanor for which you were never arrested or convicted?

a. Yes_____

b. No_____

(2) Have you ever been arrested, detained, and/or sentenced for any offense or for any fraudulent act or cited to

answer any criminal offense or violation for any reason, regardless of the intent of the event?

a. Yes_____

b. No_____

(3) Are you permanently or temporarily prohibited to perform any management or practice related to any

business by a competent court or any Government entity?

a. Yes_____

b. No_____

If you answered Yes to any of the questions in subsection F, please join the particulars on a separate sheet and

immediately notify the Office of Industrial Tax Exemption, in writing, of the facts relating to such (s) event (s).

Application under Act 22-2012

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(4) Please tell us how you learned about the tax incentives under the Act to Promote the Transfer of Investors

to Puerto Rico:

i. Attorney/tax advisor _________________________________________________________________

ii. Business contact_____________________________________________________________________

iii. Newspaper or magazine_______________________________________________________________

iv. Business Journal_____________________________________________________________________

v. Conference/Expo____________________________________________________________________

vi. Website, please provide name of organization _____________________________________________

vii. Other, please explain _________________________________________________________________

G. Signature of Application, Declaration and Acknowledgment – Please provide your signature below. By

signing below, you declare that you have read the foregoing Application and that the statements contained herein are

true to the best of your personal knowledge and belief, and you agree and acknowledge that submission of false

information in this Application will be grounds for denying the granting of a decree and you may be civil and

criminally liable in accordance with applicable statutes.

By signing below, you acknowledge that you understand that a successful criminal background check is a condition

to obtain a grant under Act 22-2012 from the Secretary of the Economic Development and Commerce of Puerto

Rico and agree to waive and relinquish all claims you may have against the Department of Economic Development

and any other agency or instrumentality of the Puerto Rico Government and their officers, agents, and employees, as

a result of participating in the criminal background check.

Name (Print)

Signature

Date

How to Submit your Application? Completed applications can be submitted by sending a PDF copy by email to

Act22@oeci.pr.gov

; or be submitted by sending the original copy to the Office of Office of Industrial Tax

Exemption, P.O. Box 192519, San Juan, Puerto Rico, 00919-2519.

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signature

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Application under Act 22-2012

7

SWORN STATEMENT

I, ___________________________, of legal age, _______________________, and resident of

_________________________ under the most solemn and binding oath, under penalty of perjury, hereby declare

that:

1. Such are my personal circumstances;

2. I have read the foregoing Application and attachments and that the statements contained herein are true to the best

of my personal knowledge and belief.

Signature

Date

AFFIDAVIT NUMBER: ________________________

Sworn and subscribed before me by ______________________________________________, of the personal

circumstances stated above to me personally known.

On the ___ day of _____________ of _____.

Notary Public

Notes:

If this document is notarized outside of Puerto Rico, include evidence regarding the authority of the notary to

administer oaths (e.g., county clerk’s certificate or similar document). Each individual must submit a separate

sworn statement.

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