Form It-Hq - Application For Georgia Headquarters Job Tax Credit
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IT-HQ
(REV 4/02)
FOR DEPARTMENT USE ONLY
Project Number __________________
GEORGIA DEPARTMENT OF REVENUE
1800 Century Center Blvd, Ste 15318
Atlanta, Georgia 30345
Date Received____________________
Phone: (404) 417-2441 Fax: (404) 417-6651
Date Reviewed by ITD___________
APPLICATION FOR GEORGIA
HEADQUARTERS JOB TAX CREDIT
Date Approved___________________
Date Denied_____________________
Tax Year End______________
MM/DD/YY
Name of Applicant / Taxpayer (Legal Name)_________________________________________________________
Headquarters Address of Applicant / Taxpayer
What was the first date on which taxes
City, State and Zip Code
were withheld on wages of employees at
such Headquarters?
__________________________________________ _____________________________________________
MM/DD/YY
What date did you establish or relocate your headquarters?
__________________________________________ _________________________________________________
MM/DD/YY
Telephone Number of Contact Person
(000) 000-0000
What date were at least 100 persons employed in
new full time jobs at new Headquarters?
Contact Person
__________________________________________ _________________________________________________
MM/DD/YY
On what date did you spend $1 million at
Contact Title
the Headquarters location?
__________________________________________ _________________________________________________
MM/DD/YY
A. TYPE OF BUSINESS (Check only one box.)
[ ] Sole Proprietor (SSN) __________
[ ] Partnership/LLC
[ ] C Corporation
[ ] S Corporation
[ ] Other (Specify) ________________
1) If Business is a Corporation, please list the state of incorporation: ______________________
2) Federal Employer ID Number: ____________________
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Parent category: Financial