Free 52301.pdf - Indiana

Application for Biodiesel Credit Certification
State Form 52301 (7-05)

FOR DEPARTMENT USE ONLY Approval Amt. Approved Date

A. Information Section Company Name Address City

TID (Taxpayer ID Number)

FID (Federal ID Number)

___________________ __________________ State Zip Code

Location of production (if different from the address listed above) City State Zip Code

B. Type of Certification Indicate the type of certification(s) being applied for: Biodiesel producer (I.C. 6-3.1-27-8) Blended biodiesel producer (I.C. 6-3.1-27-9) C. Production Date construction of production facility or expansion of existing facility for production will begin: ____________________________. · Estimated annual biodiesel production capacity in Indiana:____________ gallons. · Estimated annual blended biodiesel production capacity in Indiana:____________ gallons. D. Business Plan Applicants must submit with this application: (i) a fully completed Indiana Project Profile form; (ii) a business plan; and (iii) any other information that demonstrates that the level of production proposed by the applicant is feasible and economically viable. The business plan shall address, without limitation, each of the items set forth in I.C. 528-6-3, and must also include a timeline for financing, constructing, and operating the proposed facility. E. Signature Under penalties of perjury, I declare that I have examined this document (including the attachments hereto) and to the best of my knowledge and belief, it is true, correct, and complete. __________________________________ Printed Name and Title __________________________________ Written Signature (____)___________________ Telephone Number ________________________ Date

Mail form to: Indiana Economic Development Corporation Biodiesel Credit Certification One North Capitol Avenue, Suite 700 Indianapolis, Indiana 46204