Form 70-801-13 (Rev. 8/13)
                                                                                                                 FOR OFFICE USE ONLY
                                          Mississippi Department of Revenue
                                                Application for Certification
                                                of Economic Incentives

1.                                                             2.
               Name of Business (Please Print)                                         Name of County Where Facility is Located

                          Mailing Address                                                       Physical Location

         City                             State Zip Code                               City                        State           Zip Code

                                               Mississippi Use                                  Mississippi Direct
3. Federal ID # :                              Tax Account # :                                  Pay Permit # :
                                                               (If issued)                                         (If issued)

4. Type of Business Requesting Certification(check one)        Manufacturer/Processor                         Warehouse

   Wholesaler             Distributor           Research & Development           Other (list primary 
                                                                                       activity)
5. Detailed description of the work performed by the facility requesting certification:

6. Date company will begin making purchases for which sales/use tax exemption is requested:

7. Date construction ends and production or business begins:

8. Estimates related to the qualified           Year:                            Year:                        Year:
   activities by year, NOT cumulative:

   Increase in employment:

   Increase in annual payroll:

   Cost of construction/remodeling:

   Cost of machinery, equipment & fixtures:

   Other costs (explain):

   Total costs:

I declare that I have examined this application and, to the best of my knowledge, believe the information contained is true and correct 
and that the business referred to above qualifies for the exemption and/or credit requested. Inaccurate information or failure to comply 
with requirements for qualification will cause this certification to become void.

         Name of person signing (please print)                                                       Signature

   Telephone Number                       Email Address                                Title                                   Date

Mail To: Mississippi Department of Revenue
         Office of Tax Policy
         Post Office Box 1033                                                          See next page for rest of application
         Jackson, Mississippi 39215

Form 70-801-13 (Rev. 8/13)

                           Mississippi Department of Revenue
                                      Application for Certification
                                      of Economic Incentives

                          Check the box of which incentive(s) you are applying for
                          (Details for each incentive can be found in the Incentive Booklet on our website.)
Income Tax Credits
Jobs Tax:                 Jobs tax credit is available to manufacturers,  wholesalers, processors, research and development, 
distributors, and warehouse that increase employment by a specified minimum amount depending on the location 
of the jobs created.
Research and Development:             Must attach a letter showing for each employee and position: Title of the job,
purpose of the job, education requirements for the job, experience requirements for the job, hours worked per  
week, salary or compensation, expected hire date, and any other information showing the employee qualifies for  
the Research and Development Skills Tax Credit.
Child/Dependent Care: Must attach a letter explaining the dependent care program and a copy of the certification
from the Mississippi Department of Health.
Manufacturing Investment:  Must attach documentation about the project detailing the investment, including a
description of the project giving rise to the eligible investment and a description of the equipment and the  
capitalized cost of the eligible investment.  At least $1 million has to be spent.
Beginning date of project:                           Ending date of project:
     Date business began manufacturing in Mississippi
RED Bonds: Must attach documentation showing financial agreement with Mississippi Business Finance
Corporation (MBFC).

Sales Tax Exemptions
Construction/Expansion: Facility type (check one):        New facility       Expanding existing facility

Data Center: Must attach a copy of MDA certification letter.

Bonds:                    Must attach a copy of the bond certificate issued by Mississippi Business Finance Corporation (MBFC).

Multi Tax Incentives
Headquarters:             Must attach:
A list of all facilities inside and outside of Mississippi operating under the company's name.
A description of the activities that justify the headquarters status.
A list of the twenty(20) jobs associated with the headquarters, including such information as: Title
of each job, purpose or description of each job, education requirements for each job, experience 
requirements for eadch job, and salary or compensation amount.
* Note:  Headquarter jobs only must include officers and other high level employees, along with  
             support staff normally associated with headquarters.

Aerospace Industry:       Must attach a copy of the MDA certification letter.
MDA Certification Number (                          )  Certification Date
                                      Expiration Date
GAP:   Must attach a copy of the MDA certification letter.
MDA Certification Number (GPC-                    )   Certification Date
                                      Expiration Date
Broadband:                Must attach a list of equipment used in deployment of the broadband technologies.
County in which equipment is deployed: 
Clean Energy: Must attach a copy of the MDA certification letter.
MDA Certification Number (                          )    Certification Date
                                      Expiration Date

Please list any other incentives you wish to apply for along with the code section of such incentive.