Form R-1040 - Quality Jobs Income Tax Rebate Claim - Louisiana

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R-1040 (9/07)
Quality Jobs
Income Tax Rebate Claim
Mail to:
Office Audit Division
ICFT Unit
P. O. Box 66362
Baton Rouge, LA 70896-6362
(225) 219-2270
Please print or type.
Date of Claim (mm/dd/yyyy)
LA Revenue Account Number
Quality Jobs Contract No.
Legal Name of Business
Trade Name of Business
Mailing Address
Project Location Address
City
State
ZIP
City
State
ZIP
Effective Date of Contract or Renewal (mm/dd/yyyy)
Date Affi davit of Annual Certifi cation was certifi ed (mm/dd/yyyy)
Rebate for Tax Year Ending ...................................................................................................
Payroll ......................................................................................................................................
%
Benefi t Rate .............................................................................................................................
Rebate Earned ........................................................................................................................
DECLARATION
I declare that to the best of my knowledge of all available information, this rebate claim is true and complete and complies with all
statutes, rules and regulations, and any other policy pronouncements related to the Quality Jobs program.
Signature of Offi cer, Owner or Other (for Other, attach Power of Attorney):
Date (mm/dd/yyyy)
Name
Title

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