Form Rv-F1319501 - Jobs Tax Credit For Hiring Persons With Disabilities Business Plan

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TENNESSEE DEPARTMENT OF REVENUE
CONTROL NO.
If this is an amended plan, please check the
}
box at right; enter original Control No. above
JOBS TAX CREDIT FOR HIRING PERSONS WITH DISABILITIES
BUSINESS PLAN
(1) TAXPAYER ________________________________________________________________________________________
(2) TAXPAYER MAILING ADDRESS ________________________________________________________________________
(3) ACCOUNT NUMBER (FEIN) ___________________________________________________________________________
(4)
NEWLY CREATED TENNESSEE JOBS
(a)
(b)
(c)
(d)
(e)
(f)
FISCAL YEAR
EMPLOYEE NAME
SOCIAL SECURITY
STATE EMPLOYMENT
FULL TIME
HEALTH INSURANCE
END
NUMBER
INCENTIVE PROGRAM
(YES /NO)
PROVIDED (YES/NO)
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(5)
TENNESSEE JOB SUMMARY
FISCAL YEAR
TOTAL WORKERS WITH
TOTAL WORKERS WITH
NET INCREASE IN
END
DISABILITIES AT START
DISABILITIES AT END OF
QUALIFIED JOBS
OF FISCAL YEAR
FISCAL YEAR
FULL TIME
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PART TIME
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TOTAL
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(6) THE STATEMENTS MADE ON THIS BUSINESS PLAN ARE TRUE TO THE BEST OF MY
FOR DEPARTMENT USE ONLY
KNOWLEDGE AND BELIEF. (THIS BUSINESS PLAN MUST BE SIGNED BY THE TAX-
PA YER.)
SIGN
HERE
Taxpayer Signature (Do not print or use stamp.)
Title
Date
Phone No.
RV-F1319501
INTERNET (11-07)

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