Form Rev 41 0077E – Fill Out and Use This PDF

Application for tax credits must be made within 90 days after the actual hiring of qualified employment positions. A new application must be submitted after each group of four consecutive quarters that you project employment to increase over 15%. Positions hired after the end of four consecutive calendar quarters are not considered for this credit. Credit for a position may not be received under both this program and the Software B&O Job Credit Program or the International Services Job Credit Program. This application reflects legislative changes of House Bill 1566 effective January 1, 2008.

Business Identification

	Name of Business
						Name of Contact Person (all correspondence will be directed to this person)
	Address
						Telephone Number
	City	State	Zip Code

Department of Revenue Tax Reporting Account Number

-

-

Department of Employment Security Identification Number

-

Location of the Facility for Which Job Credits are Being Sought

Please complete one application for each separate facility that is expanding positions.

Check one:

Rural County

County

Community Empowerment Zone

Street Address

City

State

Zip Code

Does the applicant operate in other Washington locations?

Yes

No

Business Activity to be Conducted at This Business Facility

If additional space is needed please attach additional pages.

Describe your manufacturing activity:

Describe your research and development activities, if applicable:

Is the applicant engaged in the power and light business, other than in-house co-generation?

Yes

No

General Information

Check one:

If this is to be a new facility, what is the estimated cost of the project?

Business is new

Cost of structure

Cost of equipment

Business is expanding

Total

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Employment Information for this Facility (please complete attached worksheet)

Date of first hire			Application is due within 90 days of this date
Calendar Quarter for this date			(Enter this calendar quarter under Quarter A)

Employment for previous four quarters (worksheet is available, if needed)

To get 15% target, multiply by 1.15. This target is the minimum average for the next year to qualify for the credit.

Employment for current quarter plus estimates for the next three quarters

For current quarter A enter actual amount, if known, or enter estimate.

For remaining three quarters, enter estimates based on expected hired positions.

* Full Time Equivalent (FTE) positions:

Add the hours during a quarter for all part time employees who worked less than 455 hours. Divide this number by 455, and add to the total of full time employees. This is the number of FTE positions.

Annual Report is required:

Annual reports will be required for two years after application. The first annual report, due within 30 days of the end of Quarter D above, will be used to check how many employees have been hired and affirm that the 15% target has been achieved. The second annual report, due one year after the first report, will be used to confirm that the employees have been retained. See the Annual Report form for additional information.

Future Credits:

You may apply for additional credits as long as each set of four consecutive quarters continues to have expansion that meets the 15% increase. You may apply for future credits in any quarter after Quarter D above. A new application for each facility is required.

Questions:

Call (360) 902-7175 for assistance.

Return application to:

Taxpayer Account Administration

Special Credits & Assessments

PO Box 47476

Olympia, WA 98504-7476

To inquire about the availability of this form in an alternate format for the visually impaired, please call (360) 705-6715. Teletype (TTY) users may call (360) 705-6718.

REV 41 0077e (3/20/12)

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