Form 300A – Mississippi Motion Picture Incentive Pre-Qualification Form for Mississippi Residents

Certain Mississippi-based companies and residents that have filed income-tax in Mississippi taxes in each of the previous 3 years and have been associated with the production of at least 2 nationally distributed motion pictures in Mississippi within the last 10 years, serving in specific roles/jobs as defined by Mississippi Development Authority will be able to qualify for the non-resident payroll rebate and/or work in partnership with out-of-state companies which will enable the out-of-state production companies to qualify for the non-resident payroll rebate

Form 300A - Pre-Qualification Form for Mississippi Residents and Companies

Date

Main Contact

Name

Company Name

Title

Permanent Address

Street Address Address Line 2 City State ZIP Code

Mailing Address

Street Address Address Line 2 City State ZIP Code

Phone

Website

If applicable

Individual Applicant Information as Director/Producer/Production Partner

I am requesting pre-qualification for the non-resident payroll rebate as a Mississippi resident. I understand that pre-qualification can allow me to serve as a director, producer, or production partner to a motion picture production company, allowing that company to qualify for the non-resident payroll rebate for a film project eligible for the Mississippi Motion Picture Incentive.(Required)

Yes

I have worked in the following roles on at least 2 nationally distributed motion pictures produced in Mississippi within the last 10 years which would enable me to serve as a production partner.

*Credits will be verified.

List(Required)

Role

Project Title

Project Type

Year Produced

For role, choose between Director, Producer, Line Producer/Production Supervisor/UPM, Casting Director, Director of Photography, or Production Designer.

Production Company Applicant Information

I am requesting pre-qualification for my production company, production services company, or post-production company as a Mississippi-based company. I understand that pre-qualification can allow my company to serve as a production partner (as a company providing services, rental space, and/or equipment that is or are specific to film/video/media production or post-production) to a motion picture production company, allowing that company to qualify for the non-resident payroll rebate for a film project eligible for the Mississippi Motion Picture Incentive.

Yes

My company has provided services to at least 2 nationally distributed motion pictures produced in Mississippi within the last 10 years.

*Please provide rental/service agreements and copies of check stubs or bank statement for verification.

List(Required)

Role

Project Title

Project Type

Year Produced

For role, choose between Production Company, Production Services Company, or Post-Production / Visual Effects / Virtual Reality / Video Game Production Facility

Tax Requirement

Have you and/or your company filed taxes during each of the previous 3 years in Mississippi?

Yes

*Please sign and notarize the waiver from Mississippi Department of Revenue, available on the Incentives main page.

Signature

I attest the individual or production company applying for pre-qualification does not include any business organization, partnership or sole proprietorship that is owned, affiliated, or controlled, in whole or in part, by any company or person which is in default on a loan made by the State of Mississippi or a loan guaranteed by the State of Mississippi, or any company or person who has ever declared bankruptcy under which an obligation of the company or person to pay or repay public funds or monies was discharged as a part of such bankruptcy.

Name(Required)

Signature(Required)

Type name to sign.

Date

Please be advised that making false representations and/or submitting falsified documents to either the Mississippi Development Authority or the Mississippi Department of Revenue with an intent to defraud the state is a crime and may lead to both civil and criminal penalties. Miss. Code Ann. § 97-7-10 states, “Whoever, with intent to defraud the state or any department, agency, office, board, commission, county, municipality or other subdivision of state or local government, knowingly and willfully falsifies, conceals or covers up by trick, scheme or device a material fact, or makes any false, fictitious or fraudulent statements or representations, or makes or uses any false writing or document knowing the same to contain any false, fictitious or fraudulent statement or entry, shall, upon conviction, be punished by a fine of not more than Ten Thousand Dollars ($10,000.00) or by imprisonment for not more than five (5) years, or by both such fine and imprisonment.”

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