Fillable Printable Application for Employment Form - West Virginia

Application for Employment Form - West Virginia

Puerto Rico Film Project Grant | Application Form

PRFPG -1

Instructions:!Please!type!or!print!clearly.!If!the!appropriate!response!is!“not!applicable,”!please!use!“N/A.”!If!the!information!is!not!yet!available,!please!

use!“TBD.”!Capitalized!items!shall!have!the!meaning!ascribed!to!them!in!the!Puerto!Rico!Film!Industry!Economic!Incentives!Act!(“Act!27”).!Submit!two!

(2)!blue!legal!partition!folders.!!Create!an!index!and!divide!the!folder!into!the!following!sections!and!include!in!each!section!the!following!material!in!this!

order:

1. PR!Film!Project!Grant!Application!Form

2. Company!Documents

3. Per!Project!Documents

4. Exhibits

PART21:2PROJECT

1.!Project!Title

2.!Project!type!(please&check&one):

!Feature!film!

!Short!film

!Documentary!

!Music!video

!Videogame

!Television!program

!Series!in!episodes!or!mini!series,!and!pilots

!National!or!international!commercial!(no!regional!or!local)

!Recorded!live!performance

!Soundtrack!or!dubbing!recording

!Aggregated!standWalone!postWproduction

NOTE:!Project!type!CANNOT!be!(1)!!A!production!that!includes!pornographic!materialY!(2)!!A!production!that!primarily!consists!of!a!religious!or!political!advertisingY!(3)!!A!

radio!programY!(4)!!A!production!that!serves!to!market!a!product!or!service!that!is!not!a!commercial!as!stated!in!the!ActY!(5)!!A!production!with!the!primary!purpose!of!

fundraisingY!OR!(6)!!A!production!that!primarily!is!for!employee!training!or!inWhouse!corporate!advertising!or!other!similar!production.

PART22:2APPLICANT

1.!Company!Name

2.!Type!of!Entity

!Corporation

!LLC

!Partnership

!Trust

!Other:!____________

3.!Complying!individual 4.!Title!(in&relationship&to&the&applicant&company)

5.!Place!and!date!of!birth 6.!Citizenship

7.!Telephone 8.!Email!address

9.!Commercial!address 10.!Residential!address

11.!Puerto!Rico!production!office!address!(if&applicable) 12.!Federal!Employment!I.D.

13.!State!in!which!incorporated!or!registered 14.!Date!of!registration!in!Puerto!Rico

15.!Detail!your!occupations,!commercial,!and!financial!experiences!for!the!ten!(10)!years!immediately!prior!to!the!date!of!this!form!(employer,&address,&position,&type&of&

business,&and&date&of&employment).!If!necessary,!use!additional!sheet.

16.!Detail!your!formal!education,!university!name,!school!or!college,!year!of!graduation,!degrees!obtained,!and!experience!related!to!this!industry.

Page! !of!

Revised&as&of&0//201

17.$At$any$time,$have$you$been:

Official,$director,$or$promoter$of$a$company$that$has$been$declared$

insolvent?

Convicted$for$any$misdemeanor,$felony,$or$a$fraudulent$act?

Declared$in$bankruptcy$or$have$you$made$a$conveyance$for$the$benefit$of$

creditors?

Barred$permanently$or$temporarily$from$any$practice$related$to$any

business$by$any$court$or$federal,$state,$or$local$agency?

YES

If#the#answer#to#any#part#of#this#Section#10#is#“Yes,”#explain#on#a#separate#sheet.#If#during#the#period#of#association#with#the#applicant#company#an#event#causes#an#affirmative#

answer#to#any#of#the#Section#10#questions,#write#and#notify#the#Puerto#Rico#Film#Commission#of#all#facts#related#to#such#event.

18.$Have$you$or$the$company$been$at$any$time$object$of$any$order$issued$by$any$

regulatory,$administrative,$federal,$state,$or$local$agency?

YES NO

19.$Principal$contact$(responsible#for#this#application) 20.$Title$(in#relationship#to#the#applicant#company)

21.$Telephone 22.$Fax 23.$Email$address

24.$Permanent$or$physical$address 25.$Postal$address

PART%3:%PROJECT%FINANCING

1.$Has$financing$been$completed$for$this$production?

YES NO

2.$Has$financing$been$authorized$(“green$lit”)?

YES NO

3.$Describe$sources$of$financing$(name#of#entity#or#individual,#type#of#financing,#amount#&#percentage#of#budget).

4.$List$any$financing$sources$from$the$Government$of$Puerto$Rico$(tax#credits,#grants,#equity,#loans#or#other,#including#a#description#of#the#applicable#Puerto#Rico#statute#or#

program).

5.$Will$you$be$requesting$an$advance$of$the$tax$credit?

YES NO

6.$If$“Yes,”$please$specify$if$by$posting$a$Bond$to$the$Secretary$of$the$Treasury$or$submitting$evidence$of$disbursement$of$50%$of$the$Puerto$Rico$Production$Expenses.

PART%4:%DISTRIBUTION

For$a$television$series,$television$program,$music$video,$commercial,$videogame,$live$performances,$and$soundtrack$and$dubbing$recording,$the$Film$Project$is$required$to$be$

intended$for$commercial$distribution$and$or$exhibition$outside$of$Puerto$Rico.$

1.$Is$the$Film$Project$intended$for$airing,$commercial$or$exhibition$outside$of$Puerto$Rico?

YES NO

2.$Is$a$distributor$under$contract?

YES NO

3.$If$“Yes,”$please$provide$the$name$of$distributo r. 4.$Postal$address

5.$Principal$contact$and$title 6.$Telephone 7.$Email$address

NOTE:$$For$television$series,$television$program,$music$video,$commercial,$video$game,$live$performances,$and$soundtrack$and$dubbing$recording,$please$provide$a$

distribution$plan$(Exhibit%1)$and$a$letter$from$distributor$(Exhibit%2).

PART%5:%ACCOUNTING

1.$Name$of$firm$of$Certified$Public$Accountant$(proposed#auditor) 2.$Address

3.$Telephone 4.$Fax 5.$Email$address

Page$ $of$

Revised#as#of#0//201

6. Liability insurance policy number 7. Certification number

NOTE: Please provide Curriculum Vitae of CPA (Exhibit 3), Film Project Application Protocols and Validation of Production Expenses document signed by the CPA

(provided when available) (Exhibit 4), and a copy of procedural contract between the CPA and the production (provided when available) (Exhibit 5).

8. Name of Chief Internal Accountant 9. Address

10. Telephone 11. Fax 12. Email address

13. Name of bond company (if applicable) 14. Principal contact 15. Title

16. Telephone 17. Fax 18. Email address

19. Address

20. Name of 1

Production Accountant 21. address

22. Telephone 23. Fax 24. Email address

PART 6: PRODUCTION

1. Commencement date of Puerto Rico Production Expenses

2. Please specify the production phases that apply to your Film Project

! Development – please provide evidence that 50% or more of principal photography will be shot in Puerto

Rico (Exhibit 6)

! Pre-Production

! Production

! Post-Production

PART 7: TOTAL PROJECT BUDGET (please provide the total for each item)

1. Development 2. Pre-Production 3. Production

4. Post-Production 5. Total projected expenditure

PART 8: PUERTO RICO 352'8&7,21(;3(16(6%8'*(7LQFOXGHV3XHUWR5LFR5HVLGHQWDQG4XDOLILHG1RQUHVLGHQWVSHQGLQJ

1. Development 2. Pre-Production 3. Production

4. Post-Production 5. Total projected Puerto Rico Production Expenses

PART 9: 38(5725,&25(6,'(17$1'48$/,),('1215(6,'(17%8'*(7

Total projected3XHUWR5LFR5HVLGHQW

PART 10: SCHEDULE

1. Number of Principal Photography days 2. Number of Principal Photography days in Puerto

Rico

3. Dates of Principal Photography days in Puerto Rico

PART 11: LOCATIONS

1. List of locations in Puerto Rico

2. List of countries, states/provinces, cities, and towns outside of Puerto Rico

PART 12: EMPLOYMENT,138(5725,&2

1. 7RWDO1RQUHVLGHQW%HORZWKH/LQH

SHUVRQQHOWREHHPSOR\HG

7RWDO5HVLGHQW%HORZWKH/LQH

SHUVRQQHO to be employed

3. 7RWDONonresident Above the

Line to be employed

4. 7RWDO Resident Above the Line to be

employed

PART 13: KEY STAFF ON PROJECT

1. Director (name & residency) 2. Screenwriter(s) (name & residency)

3. Executive Producer(s) (name & residency) 4. Line Producer (name & residency)

Page  of  Revised as of 0//201

7RWDO1RQUHVLGHQW%HORZWKH/LQHEXGJHW

Total 1RQUHVLGHQW$ERYHWKH/LQHEXGJHW

5. Production Manager (name & residency) 6. Director of Photography (name & residency)

7. Production Designer (name & residency) 8. Wardrobe Designer (name & residency)

9. Location Manager (name & residency) 10. Casting Director (name & residency)

11. Editor (name & residency) 12. Sound (name & residency)

13. Music (name & residency)

PART 14: PUERTO RICO 5(6,'(17(;3(16(6 (please provide the total for each item)

1. Lodging expenses 2. Number of hotel room nights 3. Payroll (including fringes, benefits and per diem)

4. Production office rental and expenses 5. Food/Restaurant expenses 6. Equipment rental/purchase

7. Materials rental/purchase 8. Location fees

PART 15: AGREEMENT

The applicant certifies to the following (please check the boxes):

! The Grantee is required to release on-set production photos to the Puerto Rico Film Commission that could be

used to promote Puerto Rico and/or the Film Incentives Program.

! Excluding commercials, music videos, and soundtrack and dubbing recordings, the Grantee is required to include a

screen credit in connection with Puerto Rico’s Film Incentives Program as set forth in applicable regulations, circulars

and other administrative determinations.

! The person signing this application is duly authorized on behalf of the applicant.

! Except as otherwise described in this application, the applicant has not applied for any other economic incentives in

the form of tax credits, grants, equity, loans or similar subsidies from the Government of Puerto Rico.

! The applicant understands and is in agreement with the requirements set forth in this application, Act 27 and any

regulations, circulars or other administrative determinations promulgated thereunder, including Circular Letter

No.12-01 - Film Project Application Protocols and Validation of Production Expenses. The applicant further

understands and is in agreement that any misrepresentation in this application or failure to abide by the requirements

set forth in this application, Act 27 and any regulations, circulars or other administrative determinations promulgated

thereunder, including Circular Letter No. 12-01 - Film Project Application Protocols and Validation of Production

Expenses, may result in forfeiture or modification of the benefits granted under Act 27.

I, _________________________________________, declare that all the responses and declarations herein

submitted, including the exhibits, if any, are complete and true according to the best of my knowledge.

Given under my signature in _______________, _________, _______ on ________ of ____________of______.

(City) (State) (Country) (Day) (Month) (Year)

______________________________________

Authorized Applicant Signature

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Revised as of 0//201

COMPANY(DOCUMENTS

Please&provide&the&following&company&documents:

&&&&&&&&&&Puerto(Rico(Entities:

1. Certificate&and&Articles&of&Organization.

2. Certificate&of&no?debt&from&the&Department&of&Treasury&for&income&taxes&and&sales&and&use&taxes.&

3. Certificate&of&the&Compliance&of&Filing&Income&Taxes&for&the&past&5&years&(if&applicant&has&existed&for&less&than&5&years&or&if&during&this&

period&it&did&not&have&the&obligation&to&file&income&taxes,&it&must&supplement&the&difference&with&certifications&from&its&partners,&members &

or&shareholders).

4. Debt&Certificate&from&the&Municipal&Revenue&Collection&Center&(CRIM)&

5. Copy&of&Municipal&License&or&Certification&or&Notice&of&Commencement&of&Operations

6. Merchant’s&Registration&Certificate

Foreign(Entities:

1. Certificate&and&Articles&of&Organization.

2. Certification&of&registration&to&do&business&in&Puerto&Rico.

If(the(entity(is(engaged(in(trade(or(business(in(Puerto(Rico:

1. Certificate&of&no?debt&from&the&Department&of&Treasury&for&income&taxes&and&sales&and&use&taxes.&

2. Certificate&of&the&Compliance&of&Filing&Income&Taxes&for&the&past&5&years&(if&applicant&has&existed&for&less&than&5&years&or&if&during&this&

period&it&did&not&have&the&obligation&to&file&income &taxes,&it&must&supplement&the&difference&with&certifications&from&its&partners,&members &

or&shareholders).

Debt&Certificate&from&the&Municipal&Revenue&Collection&Center&(CRIM)&

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PER$PROJECT$DOCUMENTS

Please&provide&the&following&documents&that&apply&to&your&Film&Project.&

Aggregated&stand;alone&post;production&projects&will&require&the&

documents&set&forth&below&for&each&qualifying&media&(with&regard&to&the&

post;production&phase&only):

&&&&&&&&&Feature$Films,$Short$Films,$Series$in$Episodes,$Mini$Series,$$$

$$$$$$$$$Television$Programs$&$Pilots:

&&&&&&&&&1.&&&&&&Synopsis

&&&&&&&&&2.&&&&&&Script

&&&&&&&&&3.&&&&&&Short&bio&main&talent

&&&&&&&&&4.&&&&&&Total&itemized&budget

&&&&&&&&&5.&&&&&&Total&itemized&budget&Puerto&Rico&Production&Expenses

&&&&&&&&&6.&&&&&&Total&itemized&budget&Qualified&Nonresident

& (broken&down&between&ATL&and&BTL)&

&&&&&&&&&7.&&&&&&‘Days&out&of&days’&or&similar&document&reflecting&Qualified

&&&&&&&&&&&&&&&&&&&Nonresident&workflow

&&&&&&&&&8.&&&&&&Production&schedule&

&&&&&&&&&9.&&&&&&Plan&and&post;production&schedule&(if$applicable)

$$$$$$$$$Documentaries:

&&&&&&&&&1.&&&&&&Synopsis

&&&&&&&&&2.&&&&&&Director’s&treatment&or&script

&&&&&&&&&3.&&&&&&Short&bios&main&talent

&&&&&&&&&4.&&&&&&Total&itemized&budget

&&&&&&&&&5.&&&&&&Total&itemized&budget&Puerto&Rico&Production&Expenses

&&&&&&&&&6.&&&&&&Total&itemized&budget&Qualified&Nonresident

& (broken&down&between&ATL&and&BTL)

&&&&&&&&&7.&&&&&&‘Days&out&of&days’&or&similar&document&reflecting&Nonresident

&&&&&&&&&&&&&&&&&&&Qualified&Nonresident&workflow

&&&&&&&&&8.&&&&&&Production&schedule&

&&&&&&&&&9.&&&&&&Plan&and&post;production&schedule&(if$applicable)

$$$$$$$$$Music$Videos:

&&&&&&&&&1.&&&&&&Endorsement&letter&from&artist

&&&&&&&&&2.&&&&&&Synopsis

&&&&&&&&&3.&&&&&&Director’s&treatment&or&script

&&&&&&&&&4.&&&&&&Lyrics

&&&&&&&&&5.&&&&&&Short&bio&artist&

&&&&&&&&&6.&&&&&&Total&itemized&budget

&&&&&&&&&7.&&&&&&Total&itemized&budget&Puerto&Rico&Production&Expenses

&&&&&&&&&8.&&&&&&Total&itemized&budget&Qualified&Nonresident

& (broken&down&between&ATL&and&BTL)

&&&&&&&&&9.&&&&&&‘Days&out&of&days’&or&similar&document&reflecting&Qualified

&&&&&&&&&&&&&&&&&&&Nonresident&workflow

&&&&&&&&&10.&&&&Production&schedule&

&&&&&&&&&11.&&&&Plan&and&post;production&schedule&(if$applicable)

$$$$$$$$$

Videogames:

&&&&&&&&&1.&&&&&&Videogame&concept

&&&&&&&&&2.&&&&&&Company&bio

&&&&&&&&&3.&&&&&&Visual&layout&

&&&&&&&&&4.&&&&&&Total&itemized&budget

&&&&&&&&&5.&&&&&&Total&itemized&budget&Puerto&Rico&Production&Expenses

&&&&&&&&&6.&&&&&&Total&itemized&budget&Qualified&Nonresident

& (broken&down&between&ATL&and&BTL)

&&&&&&&&&7.&&&&&&‘Days&out&of&days’&or&similar&document&reflecting&Qualified

&&&&&&&&&&&&&&&&&&&Nonresident&workflow

&&&&&&&&&8.&&&&&&Production&schedule&

$$$$$$$$$Live$Performances:

&&&&&&&&&1.&&&&&&Endorsement&letter&from&artist

&&&&&&&&&2.&&&&&&Event&rundown&including&details&of&the&technical&film

&&&&&&&&&&&&&&&&&&recording&setup&

&&&&&&&&&3.&&&&&&Short&bio&artist

&&&&&&&&&4.&&&&&&Total&itemized&budget

&&&&&&&&&5.&&&&&&Total&itemized&budget&Puerto&Rico&Production&Expenses

&&&&&&&&&6.&&&&&&Total&itemized&budget&Qualified&Noresident

& (broken&down&between&ATL&and&BTL)&

&&&&&&&&&7.&&&&&&‘Days&out&of&days’&documents&or&similar&reflecting

&&&&&&&&&&&&&&&&&&&Qualified&Nonresident&workflow

&&&&&&&&&8.&&&&&&Production&schedule&

&&&&&&&&&9.&&&&&&Plan&and&post;production&schedule&(if$applicable)

$$$$$$$$$Soundtrack$Recording:

&&&&&&&&&1.&&&&&&Lyrics&or&compositions

&&&&&&&&&2.&&&&&&Recording&session&rundowns

&&&&&&&&&3.&&&&&&Short&bio&composer

&&&&&&&&&4.&&&&&&Total&itemized&budget

&&&&&&&&&5.&&&&&&Total&itemized&budget&Puerto&Rico&Production&Expenses

&&&&&&&&&6.&&&&&&Plan&and&post;production&schedule&(if$applicable)

$$$$$$$$$Dubbing:

&&&&&&&&&1.&&&&&&Endoresment&letter&from&client

&&&&&&&&&2.&&&&&&Copy(s)&or&script&

&&&&&&&&&3.&&&&&&Recording&session&breakdown

&&&&&&&&&4.&&&&&&Total&itemized&budget

&&&&&&&&&5.&&&&&&Total&itemized&budget&Puerto&Rico&Production&Expenses

&&&&&&&&&6.&&&&&&Production&schedule&

&&&&&&&&&7.&&&&&&Plan&and&post;production&schedule&(if$applicable)

EXHIBITS

Page&

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Revised$as$of$01/17/2013

$$$$$$$$$Commercials:

&&&&&&&&&1.&&&&&&Endorsement&letter&from&client

&&&&&&&&&2.&&&&&&Copy(s)

&&&&&&&&&3.&&&&&&Storyboard(s)

&&&&&&&&&4.&&&&&&Director’s&treatment

&&&&&&&&&5.&&&&&&Total&itemized&budget

&&&&&&&&&6.&&&&&&Total&itemized&budget&Puerto&Rico&Production&Expenses

&&&&&&&&&7.&&&&&&Total&itemized&budget&Qualified&Nonresident

& (broken&down&between&ATL&and&BTL)

&&&&&&&&&8.&&&&&&‘Days&out&of&days’&or&similar&document&reflecting&Qualified

&&&&&&&&&&&&&&&&&&&Nonresident&workflow

&&&&&&&&&9.&&&&&&Production&schedule&

&&&&&&&&&10.&&&&Plan&and&post;production&schedule&(if$applicable)