Schedule It-40qec - Enterprise Zone Qualified Employee Deduction Certificate

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Indiana Department of Revenue
SCHEDULE
PRIVACY NOTICE
Enterprise Zone
IT-40QEC
The records in this series are
Qualified Employee Deduction
State Form 21928
CONFIDENTIAL
R1/1-06
Certificate
according to the provisions of
I.C. 6-8.1-7-1 and I.C. 5-28-15-8
--- Attach to Indiana individual income tax return ---
Name of Employee
Social Security Number
Name of Enterprise Zone ___________
Date of residence in Enterprise Zone:
From ____________ To ____________
Employee’s street address
Amount of compensation for tax year
during the period of residence in
the Enterprise Zone: $_____________
City of residence
Caution: Limitation of Deduction
Enter
/
of the above amount or $7,500,
1
2
whichever is less:
$_____________
Employer
Address
Federal Identification Number
I certify that the above-named employee was paid the amount indicated as compensation for services rendered, and that
he/she is a qualified employee as defined in I.C. 6-3-2-8.
Signature of Employer
Title
Telephone Number
Date
(
)
Indiana Department of Revenue
SCHEDULE
PRIVACY NOTICE
Enterprise Zone
IT-40QEC
The records in this series are
Qualified Employee Deduction
State Form 21928
CONFIDENTIAL
R1/1-06
Certificate
according to the provisions of
I.C. 6-8.1-7-1 and I.C. 5-28-15-8
--- Attach to Indiana individual income tax return ---
Name of Employee
Social Security Number
Name of Enterprise Zone ___________
Date of residence in Enterprise Zone:
From ____________ To ____________
Employee’s street address
Amount of compensation for tax year
during the period of residence in
the Enterprise Zone: $_____________
City of residence
Caution: Limitation of Deduction
Enter
/
of the above amount or $7,500,
1
2
whichever is less:
$_____________
Employer
Address
Federal Identification Number
I certify that the above-named employee was paid the amount indicated as compensation for services rendered, and that
he/she is a qualified employee as defined in I.C. 6-3-2-8.
Signature of Employer
Title
Telephone Number
Date
(
)

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