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SECTION 1: BUSINESS CONTACT INFORMATION
Sponsor:  
Multiple Sponsor:
  If you are applying in another location with an additional sponsor (i.e., Multiple Sponsor), please download and complete the Multiple Sponsor Agreement and then upload it here:
   
Sponsor #2:
Sponsor #3:
Sponsor #4:


Contact Name:   
Contact Address:  
Contact City:  
Contact State:  
Contact Zip:    
Contact Phone:    
Contact Fax:  
Contact Email:    


SECTION 2: BUSINESS INFORMATION

Company Name:  
Company Mailing Address:  
Company Mailing City:  
Company Mailing State:  
Company Mailing Zip:    
Company County:
Company Region:

This is a certified Minority and Women-Owned Business?
Type of Business:







 
 
Class of Business:



 
   Business is locating to a 16V Incubator
Tax Treatment:

  FEIN #:      
  Website:  
Indicate the Primary North American Industrial Classification System (NAICS) Code (6 digit code) most relevant for the business applicant's operation at the Tax Free Area (TFA)
   
 
FOIL Protection:  

FOIL Information Applications to the State, including their accompanying documents, are subject to the Freedom of Information Law (FOIL) found in Article 6 of the N.Y. Public Officer Law. FOIL provides that certain records are exempt from disclosure, including those that contain (1) trade secrets, (2) information that, if disclosed, would cause substantial injury to the competitive position of your organization, or (3) critical infrastructure information. Please identify those portions of your application and accompanying documents you believe fall under these exemptions by submitting a letter with specificity any content the business deems fall within a FOIL exemption.

Blanket assertions that information is a trade secret, confidential, or proprietary are insufficient to justify withholding information under FOIL. The identified information will be reviewed and a determination will be made as to whether the information is exempt from disclosure under FOIL. The State’s determination may be appealed pursuant to POL §89(5)(c).

 


Indicate address of the Tax Free Area (TFA) the Business will locate to - please be specific be specific
Business Location Street Address:  
Business Location Building Name:
Business Location Building Number:
Business Location Floor:
Business Location Room:
Business Location City:  
Business Location State:  
Business Location Zip:    

Square Footage of TFA Business will occupy:    
Please briefly describe the predominant activity that your business will be conducting in the Tax-Free Area, citing factors such as the business' industry, primary goods produced or services rendered, geographic presence, main customers, and significant competitors. Please also explain the factors that are driving its planned growth and expansion and explain why the company is making new investments and creating jobs. 
If you are an existing business expanding in NYS, please provide please provide a description of how the business will be expanding its current operations in New York state. Also, indicate if it will attract investment from outside NYS and demonstrate how the business will create net new jobs in the Tax-Free NY Area.
Indicate if your business is moving from Out of State to NYS and from which state here:
Indicate if your business is moving to NYS from out of the Country and which Country here:
Indicate if your business is expanding to NYS from out of the state/country and which state/country expanding from here:
 
If you are a previous NYS business relocating to NYS please indicate your current location; number of employees in NYS prior to moving out of state:
 
Date Moved:  
Current Location (street, building, city, State):
Number of Employees in NYS prior to moving out of state:  
Please provide an explanation of plans to move back to NYS and demonstrate below how the business will substantially restore the jobs in NYS that it previously had moved out of state:


SECTION 3: EMPLOYMENT
Indicate the number of employees of the business in the state as of the date
this application is being completed:
 
Using the table below, please indicate the average number of employees of the business and its related persons in NYS on March 31st, June 30th, September 30th and December 31st in the state during the year immediately preceding the year in which the business submits its application to locate in a Tax Free NY Area and divide by the total number of such dates occurring within such year in which the applicant was located in NYS. Leave blank any date that the applicant was not located in NYS.
  Mar 31st June 30th Sept 30th Dec 31st Average
a. Full-Time Jobs
(35 or more hours per week)
b. Part-Time Jobs
(less than 35 hours per week)
c. Full-Time Equivalents (FTEs)
 of above Part-Time Jobs
(An FTE is any combination of two or more part-time jobs that, when combined together, constitute the equivalent of a job of at least 35 hours per week)
Total FTEs

Using the table below, please indicate the number of net new jobs (Full-time and full-time equivalents) and expected salaries for each job type for each year in the chart below. Please describe the type of job, by general category. The net new jobs should be indicated as CUMULATIVE. Do not include in the number of net new jobs any jobs that have been transferred from employment with another business located in this state, through an acquisition, merger, consolidation or other reorganization of businesses or the acquisition of assets of another business, or transferred from employment with a related person in this state.
Job Title/Category Average annual Salary Year 1
(first year of operation)
Year 2 Year 3 Year 4 Year 5
Example: Production Line Supervisor 32000 1 2 3 4 5
  Totals
Total Net New Jobs:            
Please describe how the business plans to recruit employees from the local workforce:  


SECTION 4: INVESTMENT
Please include only capital investments. Capital investment means investments in tangible personal property or other tangible property which is depreciable pursuant to section 179 (d) of the United States Internal Revenue Code. Capital investments do not include operating expenses such as office supplies, utilities, rent, and other recurring expenses.
Type of Investment Total Amount of Investment
  Year 1 Year 2 Year 3 Year 4 Year 5
Building acquisition
Building renovation
New construction
Production machinery & equipment
Furniture, fixtures & equipment
Total Projected Capital Investments
Total Investment:          



SECTION 5: BUSINESS COMPETITORS
Will the business compete with other businesses in the same community but outside of the Tax-Free NY Area? “Competitor” means a business that produces, manufactures, or sells in the community, the same or substantially similar product(s) or provides the same services, and competes for the same customers or clients as an applicant for the START-UP NY Program. “Community” means the census tract or tracts containing an approved Tax-Free NY Area and the census tracts immediately contiguous to such census tract or tracts.
   
By checking no, you are attesting that the applicant business will not compete with other businesses in the same community but outside the Tax-Free NY Area). If yes, please provide the names and addresses of the businesses with whom the applicant business will be competing.
 Name of Business Competitor 1:
Address of Competitor 1:
Name of Business Competitor 2:
Address of Competitor 2:
Name of Business Competitor 3:
Address of Competitor 3:


SECTION 6: RELATED PERSONS

Related person is defined pursuant to §465 (b) (3) (c) of the Internal Revenue Code. Include those related entities that have operations in NYS ONLY and only NYS Employees.
 
Related Entity Information 
#NameAddress PhoneFEINForm of OrganizationSole Member of SMLLC or QSSS?# Current Employees
1
 

 

2
 

 

3
 

 

4
 

 

5
 

 

6
 

 

7
 

 

8
 

 




SECTION 7: AGREEMENT

Click here to access the required attestation that must include the Statement of Consequences agreement. The signed and notarized agreement must be uploaded below:
  

Name:  
Title:
Date: