Form 42-011a - Application For Iowa Wage-Benefits Tax Credit

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Iowa Department of Revenue
Application for Iowa Wage-Benefits Tax Credit
1.
Name of Business:
2.
Address of Business:
3.
City, State, Zip Code:
4.
Tax Identification Number of Business:
5.
Description of the Activities of the Business:
6.
If the business is not engaged in the sale of tangible personal property, indicate the portion of your Iowa
sales which currently are derived from business outside Iowa.
7.
The type of tax for which the credit will be applied:
8.
Does the business file a consolidated tax return under a different tax ID number?
If yes, please provide that tax ID number:
9.
If the business is a partnership, limited liability company, S corporation, or estate or trust, please provide
the following information for each partner, member, shareholder or beneficiary. A separate schedule may
be attached.
Name:
Address:
Tax Identification Number:
Pro Rata share of earnings from the Business:
10.
For each job for which the credit is claimed, please provide the following. A separate schedule may be
attached.
Name of Employee:
Job Title of Employee:
Address and State of Residence of Employee:
Social Security Number of Employee:
Date that the Employee began work:
County where the Employee works:
Amount of wages paid for the previous 12 months:
Amount of benefits paid for the previous 12 months:
Amount of credit being claimed:
Indicate whether the job is new or retained:
Contact Person:
Telephone Number:
Date:
E-Mail Address:
This completed application is considered tax return information and is confidential
in accordance with Iowa Code sections 422.20 and 422.72.
42-011a (9/24/07)

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