Ar1036 Tuition Reimbursement Tax Credit Program Form printable pdf download

Ar1036 Tuition Reimbursement Tax Credit Program Form

AR1036

TAX CREDIT DOCUMENTATION

Tuition Reimbursement Tax Credit Program

Tax Year Beginning

and Ending

Section A.

Name of Entity:____________________________________________________________

Address:__________________________________________________________________

City, State, Zip Code:________________________________________________________

FEIN/SSN:________________________________________________________________

SIC CODE:________________________________________________________________

Eligibility category (see next page, enter a letter A through H) ___________.

If category "B" or "D", enter the percentage of your total

sales that are outside the State of Arkansas

___________.

OWNERSHIP OF BUSINESS

Individual

Partnership (Complete Section C)

Taxable Corporation

LLC (Complete Section C)

Fiduciary

Subchapter-S (Complete Section C)

Section B.

Employee’s Name*

Tuition, books, & fees

For Term Ending

reimbursed to employee ($)

(date)

Total Amount Reimbursed

Total Tax Credit = (total amount reimbursed) x (0.30) =

*If more space is needed for employees’ names, attach additional sheet(s) and enter the total amount

reimbursed for all employees in the space immediately above.

Revised January, 2005

Ar1036 Tuition Reimbursement Tax Credit Program Form