Economic Incentive Interest Form
City of Whitehall
Type of incentive being inquired about (check all that apply)
Property Tax Abatement (CRA)
Income Tax Reimbursement
Tax Increment Financing (TIF)
Unsure - I would like to request more information
Applicant and Business Information
Name of Business
Name
First Name
Last Name
Relationship to Business
(Owner, Manager, CEO, CFO, etc.)
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Federal Tax ID Number
(Business/User)
Federal Tax ID Number
(Borrower, If different)
Principal Product(s)/Service(s)
Business Type
Four Digit SIC#/NAICS Code
Date Established
-
Month
-
Day
Year
Date
Current number of employees in Ohio
Project Details
Proposed Project Location (Address)
Project Description
Please note and existing/past economic development incentives
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Will this project incorporate LEED (Leadership in Energy and Environment) design, energy conservation or environmental presentation features?
If yes, please explain. If no, please list N/A
Is this a retention of a current Whitehall business?
Yes
No
Full time jobs retained
Part time jobs retained
Is this a relocation of an existing business?
Yes
No
Full time jobs relocated
Part time jobs relocated
What is the new payroll associated with the project?
Please estimate increase
Is this an expansion or consolidation of operations (or neither)?
Expansion
Consolidation
Neither
Project Financial Information
Project Costs
Land Cost
Building Cost
Tenant Improvement(s) Cost
Other
Total Project Cost
Project Funding
Owner Equity
Requested City Funding (If applicable)
Other
Other
Total Project Funding
Principal Officers/Owner
Please list all individuals required for the business to enter into legally binding agreements
Name
First Name
Last Name
Percent Ownership
Address
(If different from business)
Name
First Name
Last Name
Percent Ownership
Address
(If different from business)
Name
First Name
Last Name
Percent Ownership
Address
(If different from business)
Project Timeline
Project Start Date
-
Month
-
Day
Year
Date
Project End Date
-
Month
-
Day
Year
Date
When is project financing/program needed by?
Applicant Signature
Signature
Clear
Date Signed
-
Month
-
Day
Year
Date
Retype Full Name
First Name
Last Name
Please verify that you are human
*
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