Application for Certification of Qualified Investments 
Form  8942
                                Eligible for Credits and Grants Under the Qualifying 
(June 2010)                                                                                                            OMB No. 1545-2175
                                Therapeutic Discovery Project Program
Department of the Treasury             ▶ See separate instructions for required attachments.
Internal Revenue Service 
Part I      Applicant Information                          Check if this is an amended application
1     Name of applicant                                                                            2 Taxpayer identification number (TIN)

3     Number and street                                                                                                Room/suite

4     City, town, or post office, state, and ZIP code

5     Telephone number
6     URL address for applicant's website
7     Is the applicant a member of an affiliated group filing consolidated returns?  .       .  .  . . .     . . .     Yes                              No
      If "Yes," complete lines 8 through 12.
8     This corporation has been a member of this group:
a           For the entire year
b           From            /   / 20               until          /        / 20            .
9     Name of the common parent of the affiliated group                                         10   Employer identification number (EIN)

11    Number and street                                                                                                Room/suite

12    City, town, or post office, state, and ZIP code

13    Contact person. Attach a properly completed Form 2848, Power of Attorney and Declaration of Representative, if necessary. 
      See instructions. 
a     Name of contact person
b     Number and street                                                                                                Room/suite

c     City, town, or post office, state, and ZIP code

d     Telephone number                                                    e    Fax number

14a   Name of the project
b     Description of the project (see instructions)

Part II     Certification and Grant Election Information (see instructions) 
15    Enter  the  number  of  employees  in  all  businesses  of  the  applicant  on  the  date  this  application  is 
      submitted. See instructions  . . .    .      . .   . .  .   . .  .   .     . .  .    . .  .  . . .     . . . ▶
      If more than 250, do not continue with this application.
16    Are the applicant and any other entities considered to be a single employer under section 52(a) or (b) or 
      section 414(m) or (o)? See instructions  .     .   . .  .   . .  .   .     . .  .    . .  .  . . .     . . . ▶   Yes                              No
      If "Yes":
      • Attach a statement listing the name, address, and employer identification number (EIN) for each of the other entities; and
      • Applicant certifies it has 250 or fewer employees, taking into account the employees of these other entities, on the date this 
      application is submitted. 
17    Is the applicant electing for this application for certification to be an application for a grant for a tax year beginning in:
a     2009?                 Yes No                   If "Yes" for either  aor  b,complete lines 18 and 19. 
b     2010?                 Yes No                   If "No" to both  aand  b,skip to line 20.
18    Enter the applicant's Data Universal Numbering System (D-U-N-S) number. See instructions. ▶
19    Check the applicable box that describes the applicant. If any of the following describes the applicant, the applicant is not 
      eligible for a grant. 
            Federal, state, or local government or any political subdivision, agency, or instrumentality thereof.
            Organization described in section 501(c) and exempt from tax under section 501(a).
            Entity referred to in section 54(j)(4).
            Partnership or other pass-through entity with a government or any political subdivision, agency, or instrumentality thereof, section 
            501(c) organization, or section 54(j)(4) entity as a direct or indirect partner (or other direct or indirect holder of an equity or profits 
            interest). Note: Do not check this box if such entity owns only an indirect interest in the applicant through a C corporation. 
For Privacy Act and Paperwork Reduction Act Notice, see instructions.                        Cat. No. 37758D           Form 8942 (6-2010) 

Form 8942 (6-2010)                                                                                                                                     Page 2
Part II      Certification and Grant Election Information (continued)
20   Will this project create and sustain (directly or indirectly) high-quality, high-paying jobs in the United States?               Yes              No
21   Enter the number of full-time and part-time employees in the United States whose work is directly billed to the project and the
     average salaries of the employees in each category. See instructions.
                             Employees                                                 Number of employees            Average salaries of the employees
a    Full-time
b    Part-time
22 a Enter the number of contractors in the United States paid for work on the project .                      . . .   .     .  .
b    Enter the average monthly hours of the contractors entered on line 22a                   .      . .    . . . .   .     .  .
c    Enter the average monthly compensation of the contractors entered on line 22a.                         . . . .   .     .  .
23   Will  this  project  advance  United  States  competitiveness  in  the  fields  of  life,  biological,  and  medical 
     sciences? .   .     .   . .      . .  .        . . . . . . .         .       . .  . . .  .      . .    . . . .   .     .  .      Yes              No
24   As of the date this application is submitted, is the project active, terminated, or suspended? Check one. 
         Active                                               Terminated                                                              Suspended
25   If the project is terminated or suspended for any of the failures below, check all boxes that apply.
         The project failed a clinical trial.
         The project failed a pre-clinical research milestone.
         The project failed to secure FDA licensure.
     If the applicant checked any of the boxes above, do not continue with this application.
26   Will the project produce a new or significantly improved technology, or a new application of or significant 
     improvement to existing technology, as compared to commercial technologies currently in service?                          .      Yes              No
27   Is the project expected to lead to the construction or use of a contract production facility in the United
     States in the next 5 years?  .        .        . . . . . . .         .       . .  . . .  .      . .    . . . .   .     .  .      Yes              No
Part III     Qualified Investment (see instructions)
Complete columns (a), (b), and (c), as 
   applicable. See instructions.                          (a) 
                                                    As of September 30, 2010             (b)                      (c) 
   Complete column (a) only for 2009 grant            (tax year 2009 only)            Tax year 2009           Tax year 2010  
applications if the  applicant's 2009 tax year ends   (see instructions)  
         after the application date. 
28   Qualified investment derived 
     from employee wages.
29   Qualified investment derived 
     from supplies and lab costs.
30   Qualified investment derived 
     from depreciable property.
31   Qualified investment derived 
     from third-party contractors.
32   Qualified investment derived 
     from other costs.
33   Amount in line 30 attributable to 
     qualified progress expenditures.
34   Total. Add lines 28 through 32 in 
     each column.
35   Qualified investment for which certification is requested. Add line 34 columns (b) and (c).          
36   This application is for certification of qualified investment, related to a qualifying therapeutic discovery project, for (check only one):
             Tax year beginning in 2009 only. Enter the ending date of the tax year                  . .    . . . .   .     .  ▶      /    /
             Tax year beginning in 2010 only. Enter the ending date of the tax year  .                 .    . . . .   .     .  ▶      /    /
             Tax years beginning in 2009 and 2010. Enter the ending date of the tax year for 2009  .                  .     .  ▶      /    /
             and for 2010  .   .      . .  .        . . . . . . .         .       . .  . . .  .      . .    . . . .   .     .  ▶      /    /
Sign Here    Under penalties of perjury, I declare that I have examined this submission, including the accompanying documents, and, to the best of my knowledge and 
             belief, all of the facts contained herein are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which 
Keep a copy  preparer has any knowledge.
of this form 
for your 
records.     Signature of▲ Applicant                                              Date                 Title
Paid         Preparer’s                                                                  Date                                    Preparer’s SSN or PTIN
                                                                                                              Check if self-
             signature                ▲                                                                       employed
Preparer’s   Firm’s name (or                                                                                                EIN
Use Only     yours if self-employed), 
             address, and ZIP code                                                                                          Phone no. 
                                                                                                                                      Form 8942 (6-2010)