Application For Job Creation Tax Credit - Pennsylvania Department Of Revenue (Page 4 of 4) in pdf

Application For Job Creation Tax Credit - Pennsylvania Department Of Revenue Page 4

Attachment A: Employment Affidavit

Applicants for Job Creation Tax Credits are required to complete and sign this affidavit.

Indicate below the number of full-time employees for each item requested. Begin with the desired start date and work backward three

years. Do not go by the calendar year. Also include the average hourly wage to be paid to the new hires, excluding benefits.

This affidavit will be reviewed to determine the base employment. The employment numbers provided will be averaged. The higher

of the averaged number of the employment at the time of the start date will result in the base employment. Businesses must either

create 25 new full-time jobs in Philadelphia or increase the base employment by 20% within Philadelphia to qualify for Job Creation

Tax Credits.

All Philadelphia Jobs

Philadelphia Jobs

Paying More Than

150% of Federal

Minimum Wage

Employment at the time of the desired start date:

Employment 1 year prior to the desired start date:

Employment 2 years prior to the desired start date:

Employment 3 years prior to the desired start date:

Average hourly wage to be paid to new employees, excluding benefits:

/hour

Under penalties of perjury, I declare that I have compiled the information contained in this schedule, and to the best of my knowledge

and belief, it is true, correct and complete.

Preparer’s Name

Preparer’s Title

Preparer’s Signature

Date

Application For Job Creation Tax Credit - Pennsylvania Department Of Revenue Page 4