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 InformationPlease 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
3
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
4
(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
5
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
6
(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.
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.
click to sign
signature
click to edit
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.