Name ___________________________
EIN _______________
Location _________________________________
PART C – DETERMINING QUALIFIED EMPLOYEES AND CREDIT
(see instructions for available credit amounts)
(A)
(B)
(C)
(D)
(E)
(F)
Year End Date: __ __ __ __
Year End Date: __ __ __ __
Year End Date: __ __ __ __
Year End Date: __ __ __ __
Year End Date: __ __ __ __
Month
Number of Base Employees
Number of Employees
Number of Employees
Number of Employees
Number of Employees
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37. Total No. of Employees
38. Average Employees
39. Base Employees
40. Qualified Employees
41. Decrease in Employees
42. Adjusted Employees
43. TOTAL Employee Credit
PART D – DETERMINING QUALIFIED INVESTMENT AND CREDIT
(see instructions for available credit amounts)
(A)
(B)
(C)
(D)
(E)
(F)
Year End Date: __ __ __ __
Year End Date: __ __ __ __
Year End Date: __ __ __ __
Year End Date: __ __ __ __
Year End Date: __ __ __ __
Month
Monthly Base Investment
Monthly Investment
Monthly Investment
Monthly Investment
Monthly Investment
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56. Total Monthly Investment
57. Average Investment
58. Capitalized Rents
59. Total Investment
60. Base Investment
61. Increase in investment
62. Nonrelated Investment
63. Avg. Qualified Investment
64. Decrease in Investment
65. Adjusted Investment
66. Investment Credit Factor
67. TOTAL Investment Credit
68. TOTAL Credit
69. Credit Used
70. Carry Forward
2