Form 8942 (6-2010)
Page 2
Part II
Certification and Grant Election Information (continued)
20
Will this project create and sustain (directly or indirectly) high-quality, high-paying jobs in the United States?
Yes No
21 Enter the number of full-time and part-time employees in the United States whose work is directly billed to the project and the
average salaries of the employees in each category. See instructions.
Employees Number of employees Average salaries of the employees
a Full-time
b Part-time
22 a Enter the number of contractors in the United States paid for work on the project . . . . . . .
b Enter the average monthly hours of the contractors entered on line 22a . . . . . . . . . .
c Enter the average monthly compensation of the contractors entered on line 22a. . . . . . . .
23 Will this project advance United States competitiveness in the fields of life, biological, and medical
sciences? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes No
24 As of the date this application is submitted, is the project active, terminated, or suspended? Check one.
Active Terminated Suspended
25 If the project is terminated or suspended for any of the failures below, check all boxes that apply.
The project failed a clinical trial.
The project failed a pre-clinical research milestone.
The project failed to secure FDA licensure.
If the applicant checked any of the boxes above, do not continue with this application.
26
Will the project produce a new or significantly improved technology, or a new application of or significant
improvement to existing technology, as compared to commercial technologies currently in service? .
Yes No
27 Is the project expected to lead to the construction or use of a contract production facility in the United
States in the next 5 years? . . . . . . . . . . . . . . . . . . . . . . . . .
Yes No
Part III
Qualified Investment (see instructions)
Complete columns (a), (b), and (c), as
applicable. See instructions.
Complete column (a) only for 2009 grant
applications if the applicant's 2009 tax year ends
after the application date.
(a)
As of September 30, 2010
(tax year 2009 only)
(see instructions)
(b)
Tax year 2009
(c)
Tax year 2010
28 Qualified investment derived
from employee wages.
29 Qualified investment derived
from supplies and lab costs.
30 Qualified investment derived
from depreciable property.
31 Qualified investment derived
from third-party contractors.
32 Qualified investment derived
from other costs.
33 Amount in line 30 attributable to
qualified progress expenditures.
34 Total. Add lines 28 through 32 in
each column.
35 Qualified investment for which certification is requested. Add line 34 columns (b) and (c).
36
This application is for certification of qualified investment, related to a qualifying therapeutic discovery project, for (check only one):
Tax year beginning in 2009 only. Enter the ending date of the tax year . . . . . . . .
▶
/ /
Tax year beginning in 2010 only. Enter the ending date of the tax year . . . . . . . .
▶
/ /
Tax years beginning in 2009 and 2010. Enter the ending date of the tax year for 2009 . . .
▶
/ /
and for 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . .
▶
/ /
Sign Here
Keep a copy
of this form
for your
records.
Under penalties of perjury, I declare that I have examined this submission, including the accompanying documents, and, to the best of my knowledge and
belief, all of the facts contained herein are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which
preparer has any knowledge.
Signature of Applicant
Date
Title
Paid
Preparer’s
Use Only
Preparer’s
signature
▲
Date
Check if self-
employed
Preparer’s SSN or PTIN
Firm’s name (or
yours if self-employed),
address, and ZIP code
▲
EIN
Phone no.
Form 8942 (6-2010)
