Economic Incentive Interest Form

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
Upload additional documents here to support your project description as needed

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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

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
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Economic Incentive Interest Form

Applicant and Business Information

Project Details

Project Financial Information

Principal Officers/Owner

Project Timeline

Applicant Signature