Data Collection Form for Tax Credits and Grants

Qualified Active Low-Income Community Business (QALICB)
This is the standard intake form for Community Development Entities

The federal New Markets Tax Credit Program (NMTC) is designed to foster private investment in businesses and economic development activities in low-income communities. These qualified loans are generally provided at concessionary rates and/or terms to projects operating in a low-income community or that serve low-income populations.


The CDE named above only utilizes NMTCs for projects or businesses that have significant community impacts, particularly on the low-income community where the project is located. It is important to establish that a project is eligible by determining if it is in a low-income community. The information provided in this intake form is critical to establish that a project is eligible for New Markets Tax Credit financing as well as the community and economic impacts of the proposed investment.


This Intake Form is not intended to constitute legal or tax or accounting advice and the named CDE makes no representations as to such matters. The named CDE shall not be liable for any use of, for any decision made or action taken in reliance upon, this NMTC Intake Form or from the information provided herein. You should consult your own legal counsel and advisors as the suitability of a New Markets Tax Credit transaction or any financing for your project. Our acceptance and/or review of this Intake Form is not a commitment to provide NMTCs for a project and is not a binding commitment for any terms of conditions of any transactions that are consummated with the named CDE or its affiliates in the future.


Please make sure that you complete this application fully and attach as much information so we can review the project accurately. Projects that satisfy the preliminary criteria for the NMTC program will be evaluated more thoroughly by CDE staff and additional due diligence and other information may be requested from the Applicant.


By signing below and submitting this form, you attest that the information herein is, to the best of your knowledge, true and accurate. Further, you agree to authorize the named CDE to include, at our discretion, the project in our pipeline narrative to the CDFI Fund and to share with our legal counsel, consultants, and Board Members details of your project as well as discuss it with any applicable third parties including other sources of financing you have identified herein.

Answer Each Question Below:

NOTE: Please Validate ALL DATA Prior to submitting, as fields will be reset. ​

Note: The completion of this form does not commit HRF to provide New Markets Tax Credit allocation or financing for the Applicant. Allocation will be made available to qualified applicants approved by the Heartland Renaissance Fund Advisory Board. The completed form will assist HRF in determining if a project 1) meets New Markets Tax Credit program requirements 2) Generates community impact as determined by HRF and 3) Otherwise meets the requirements of all New Markets Tax Credit program rules, laws, and other HRF internal requirements. We reserve the right to request additional information in order to complete a review of this Application. You may attach supplemental files; however, the inclusion of other documents should be in addition to completing the following form, rather than in place of filling out all sections.


Items that must be included as attachments:


Project narrative and details


Borrower pro-forma financials or projections and appraisals, if any Project details, renderings, and budgets


Schedule of non-qualified financial property, if any Proposed construction schedule


Prior year financial statements, if currently operating Community and economic impact details

Support letters


Term Sheets / Commercial Bank Commitments (if any)

Through the NMTC Program, the CDFI Fund allocates tax credit authority to Community Development Entities (CDEs) through a competitive application process. CDEs are financial intermediaries through which private capital flows from an investor to a qualified business located in a low-income community. 

CDEs use their authority to offer tax credits to investors in exchange for equity in the CDE. Using the capital from these equity investments, CDEs can make loans and investments to businesses operating in low-income communities on better rates and terms and more flexible features than the market. The NMTC program is flexible regarding project type and purpose. 

QALICBs can be used to finance equipment, operations, or real estate. Real estate financing can purchase or rehabilitate retail, manufacturing, agriculture, community facilities (e.g., health services, museums, or charter schools), rental or for-sale housing, or combinations of these. A “low-income community” is defined as any population census tract where the poverty rate for such tract is at least 20% or in the case of a tract not located within a metropolitan area, median family income for such tract does not exceed 80% of statewide median family income, or in the case of a tract located within a metropolitan area, the median family income for such tract does not exceed 80% of the greater of statewide median family income or the metropolitan area median family income. The actual cash investment made by the investor to the CDE, which is referred to as the equity investment, is the first step in defining a QEI. 

This cash investment eventually qualifies for the NMTC provided that the CDE makes qualified low income community investments (QLICIs). A QEI is, in general, any equity investment in a CDE if: 

1. Such investment is acquired by the investor at its original issue (directly or through an underwriter) solely in exchange for cash, 

2. Substantially all (at least 85%) of the cash is used by the CDE to make qualified low-income community investments (QLICI), and 

3. The investment is designated by the CDE as a QEI on its books and records using any reasonable method. The term equity investment means any stock in an entity which is a corporation, and any capital interest in an entity which is a partnership.

Name of the Sponsor of the Qualified Active Low - Income Community Business (QALICB)

Information required for Financial Analysis

NOTE: Please Validate ALL DATA Prior to submitting, as fields will be reset.

Medical Facility Operators (select type and enter # of people for each type)

NOTE: Please Validate ALL DATA Prior to submitting, as fields will be reset.

Names of Owners Holding 20% or more of the Holding Company

NOTE: Please Validate ALL DATA Prior to submitting, as fields will be reset. ​

Property Appraisal

NOTE: Please Validate ALL DATA Prior to submitting, as fields will be reset. ​

“This appraisal assumes that all of the information obtained
for analysis is accurate: this information has been verified to the
extent possible by the appraisers….At the request of the client
and for purposes of this appraisal, the subject is valued as if
the improvement renovations/updates were completed and
available to the market as of the completion date.”

New Markets Tax Credits

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