"Qualified Maryland Cybersecurity Seller Application for Certification" - Maryland

Qualified Maryland Cybersecurity Seller Application for Certification is a legal document that was released by the Maryland Department of Commerce - a government authority operating within Maryland.

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Download "Qualified Maryland Cybersecurity Seller Application for Certification" - Maryland

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BUY MARYLAND CYBERSECURITY TAX CREDIT
QUALIFIED MARYLAND CYBERSECURITY SELLER
APPLICATION FOR CERTIFICATION FOR TAX YEAR 2018
WARNING: False statements made knowingly and willfully in this application for certification
For Internal Use Only
as a Qualified Maryland Cybersecurity Seller, including affidavits or other supporting
documents submitted therewith, are punishable by law. All statements and documents are
subject to verification.
1. Full Legal Name of Organization
2. Federal Employer Identification Number (FEIN)
3. Unemployment Insurance Number
4. Legal Form of Entity
C Corporation
S Corporation
LLC
LLP
Limited Partnership
General Partnership
LLLP
Other:
5. Primary Contact Person
Last Name
Suffix (Jr. Sr. III)
First Name
Middle Name
Title / Occupation
Main Telephone Number (Include Area Code)
Business Telephone Number (Include Area Code)
Email Address
6. Secondary Contact Person
Last Name
Suffix (Jr. Sr. III)
First Name
Middle Name
Title / Occupation
Main Telephone Number (Include Area Code)
Business Telephone Number (Include Area Code)
Email Address
7. Business Address
Street:
City:
State:
Postal Code:
County:
8. Check All That Apply
Less than $5,000,000 in annual revenue
Minority or Woman-Owned Business
Located in a Historically Underutilized Business
Veteran-Owned or Service-Disabled Veteran Owned Business
(HUB) Zone
Veteran Ownership %
Page 1 of 4
BUY MARYLAND CYBERSECURITY TAX CREDIT
QUALIFIED MARYLAND CYBERSECURITY SELLER
APPLICATION FOR CERTIFICATION FOR TAX YEAR 2018
WARNING: False statements made knowingly and willfully in this application for certification
For Internal Use Only
as a Qualified Maryland Cybersecurity Seller, including affidavits or other supporting
documents submitted therewith, are punishable by law. All statements and documents are
subject to verification.
1. Full Legal Name of Organization
2. Federal Employer Identification Number (FEIN)
3. Unemployment Insurance Number
4. Legal Form of Entity
C Corporation
S Corporation
LLC
LLP
Limited Partnership
General Partnership
LLLP
Other:
5. Primary Contact Person
Last Name
Suffix (Jr. Sr. III)
First Name
Middle Name
Title / Occupation
Main Telephone Number (Include Area Code)
Business Telephone Number (Include Area Code)
Email Address
6. Secondary Contact Person
Last Name
Suffix (Jr. Sr. III)
First Name
Middle Name
Title / Occupation
Main Telephone Number (Include Area Code)
Business Telephone Number (Include Area Code)
Email Address
7. Business Address
Street:
City:
State:
Postal Code:
County:
8. Check All That Apply
Less than $5,000,000 in annual revenue
Minority or Woman-Owned Business
Located in a Historically Underutilized Business
Veteran-Owned or Service-Disabled Veteran Owned Business
(HUB) Zone
Veteran Ownership %
Page 1 of 4
BUY MARYLAND CYBERSECURITY TAX CREDIT
APPLICATION FOR CERTIFICATION AS A
QUALIFIED MARYLAND CYBERSECURITY SELLER
9. Identify Cybersecurity Technologies and Services
(Provide the name of each cybersecurity technology or service sold by the company applying for certification in Column A,
identify whether it is a cybersecurity technology or a service in column B, the SKU or part number in column C, and the
function of the NIST Framework for the cybersecurity Service in Column D)
A
B
C
D
Name of Cybersecurity
Technology or Service
SKU or Part number Cybersecurity Technology
NIST Framework:
Technology or Service
Identify (I)
Protect (P)
Detect
(D)
Respond (R)
Recover (Re)
Proof of intellectual property as outlined in Section 10.3(a) must be provided for proprietary technologies and products listed here.
10. Attachments – Please attach the following information to your application. Incomplete information will delay the
processing of the applications for QMCS certification. Failure to submit required information and documentation will cause
an application not be processed.
10.1
A current certified copy of organization’s articles of incorporation, articles of organization, partnership agreements,
or other organizing documents issued within the last 30 days.
10.2
The names, business addresses and titles of all officers, directors, managing members, general partners, or other
persons with management authority over the business of the applicant.
10.3
Submit a copy of a formal business plan that describes in sufficient detail the business and operations of the
company to establish that the company is organized and operated as a cybersecurity company as defined in the
Act, including general descriptions of the cybersecurity technology or services sold, used, or intended to be sold,
used or developed.
A business plan should include: Executive Summary; History of Entity; Descriptions of Technologies, Products,
and Eligible Services; Intellectual Property; Market Analysis; Product Development; Pricing Strategy;
Competition; Company Leadership and Necessary Appendices.
As part of or supplemental to the business plan include:
10.3(a) Copies of licenses, patents, patents pending, copyrights, trademarks, or evidence of trade secrets for
proprietary technologies and products listed in Section 9.
10.3(b) To the extent not listed in 10.3(a), provide verification of any other intellectual property - list of:
patents and patent numbers already held; for pending patents submit confirmation of filed
applications; licenses; trademarks; or evidence of trade secrets.
10.3(c) Complete financial statements that include a Balance Sheet and Income Statement. The Balance Sheet
and Income Statement should include: historical revenues and expenses; present and projected
revenues and expenses; and Research and Development expenses clearly segregated from Selling,
General, and Administrative expenses.
Page 2 of 4
BUY MARYLAND CYBERSECURITY TAX CREDIT
APPLICATION FOR CERTIFICATION AS A
QUALIFIED MARYLAND CYBERSECURITY SELLER
10.4
Detailed descriptions of the business activity, which may include but is not limited to: financial, research, and
production activity, occurring at the company’s headquarters. The physical address of the company’s headquarters
and any additional company sites must be provided.
10.5
A screenshot from the Maryland Department of Assessment and Taxation’s website
(https://egov.maryland.gov/BusinessExpress/EntitySearch) demonstrating a company is in good standing.
Clicking on “View Business Detail” after searching a company’s name provides the webpage for which a
screenshot needs to be and submitted.
10.6
A copy of a Good Standing Certificate from the Comptroller of Maryland that shows a company is current with its tax
obligations. A Good Standing Certificate may be requested at:
http://comptroller.marylandtaxes.gov/Vendor_Services/Accounting_Information/General_Information/Good_Stand
ing_Certificate.shtml
10.7
For companies claiming minority or woman-owned status, a copy of a company’s Minority Business Enterprise
(MBE) certification from the Maryland Department of Transportation. The application for the MBE program is
available at:
https://mbe.mdot.maryland.gov/apply/
10.8
For companies claiming Veteran-Owned or Service-Disabled Veteran-Owned status, a copy of the DD 214 for the
primary veteran owner, or copy of the company’s certification from United States Department of Veteran’s Affairs
as a Veteran Owned Small Business (VOSB) or Service-Disabled Veteran-Owned Small Business (SDVOSB). The
percentage of veteran ownership must be provided in Section 8 of the application. Information for VOSB and
SDVOSB certifications are available at:
https://www.va.gov/osdbu/verification/
10.9
For companies claiming location in a HUB Zone, a copy of the company’s HUB Zone certification from the
United States Small Business Administration. Information on HUB Zones is available at:
https://www.sba.gov/offices/headquarters/ohp/spotlight
and a company can find out if it is located in a HUB
Zone at:
https://maps.certify.sba.gov/hubzone/map#center=39.828200,-98.579500&zoom=5
11. Additional Information
Has or does the Applicant, or any partner, director, officer, member, or principal stockholder:
11.1
Been convicted of a criminal offense other than a traffic violation?
Yes
No
11.2
Have a current bankruptcy proceeding for dissolution?
Yes
No
11.3
Owe any outstanding judgements?
Yes
No
Page 3 of 4
BUY MARYLAND CYBERSECURITY TAX CREDIT
APPLICATION FOR CERTIFICATION AS A
QUALIFIED MARYLAND CYBERSECURITY SELLER
SIGNATURE REQUIRED
12. Oath and Signature
Collection of Personal Information: In accordance with Executive Order 01.01.1983.18, the Department of Commerce
(“COMMERCE”) advises you as follows: Certain personal information requested by the Department is necessary in determining
your eligibility. Failure to disclose this information may result in the denial of one of these benefits or services. Availability of
this information for public inspection is governed by the provisions of the Maryland Public Information Act, General Provisions
Article, Section 4-101 et seq. of the Annotated Code of Maryland. This information will be disclosed to appropriate staff of the
Department and other public officials for purposes directly connected with administration of the program for which its use is
intended. Such information is routinely shared with State, federal or local government agencies. You have the right to inspect,
amend or correct personal records in accordance with the Maryland Public Information Act.
Publicity: The applicant agrees that COMMERCE may issue press releases and otherwise publicize information about the
applicant’s qualification for the Buy Maryland Cybersecurity Tax Credit.
Revocation of Certification: Commerce may deny or revoke a company’s certification as a Qualified Maryland Cybersecurity
Company if Commerce discovers any material mistake, misrepresentation, or fabrication by a company during the verification
processor at any time, and its eligibility for participating in the BUY Maryland Cybersecurity Tax Credit Program.
Affidavit: I solemnly affirm under the penalties of perjury and upon personal knowledge that the business applying for the
Buy Maryland Cybersecurity Tax Credit is not in default of any terms of a contract, loan, grant, or other agreement with the
State of Maryland, or political subdivision in Maryland.
I further affirm that all information in this application and in all supporting documentation is true and correct.
X_______________________________________________
_______________________________________
Applicant Signature
Date (mm-dd-yyyy)
________________________________________________
_______________________________________
Print Name
Title
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