Arizona Form 304 Draft - Enterprise Zone Credit

Name:

TIN:

Employees at Enterprise Zone Location

Form 304-1 (2010)

Complete a Form 304-1 for each employee at the enterprise zone location, whether or not the employee is in a qualiﬁ ed employment position. See

instructions for Form 304-1 (included with Instructions for Form 304, pages 3 - 4) about providing the requested information in an alternative format.

1 Employee name

2 Employee’s taxpayer identiﬁ cation number (TIN)

3 Employee’s residence address

4 What year is this employee?

First

Second

Third

Fourth or more

5a Is the residence address listed on line 3 inside or outside of an enterprise zone that is located in the same county in which

the business is located?

inside

outside

5b If the answer on line 5a is inside, list the name of the enterprise zone in which the employee’s residence address is located

6 Employee’s residence address AT DATE OF HIRE

7a Is the residence address listed on line 6 inside or outside of an enterprise zone that is located in the same county in which

the business is located?

inside

outside

7b If the answer on line 7a is inside, list the name of the enterprise zone in which the employee’s residence address was located

8 Current date of employment

9a If employee was previously employed by the business, list the previous date of employment. (See instructions.)

9b If employee was previously employed by the business, list the date of separation

10a Is the employee in a permanent full time position?

Yes

10b If the answer to line 10a is yes, list the number of hours the employee actually worked during the taxable year (see

instructions)

11a Employee’s annual compensation for the taxable year $

11b Employee’s hourly wage $

/hour

12a Total cost of health insurance provided by employer for employee. (See instructions.) $

12b Total cost of health insurance for employee paid by employer. (See instructions.) $

13 Is this employee in a new qualiﬁ ed employment position?

Yes

14a Has this employee been substituted for another employee in a qualiﬁ ed employment position?

Yes

14b If answer on line 14a is yes, list the date of substitution

and indicate whether the individual is a

second year employee or a third year employee. See instructions before answering this question.

Check only one box.

second year employee

third year employee

ADOR 10130 (10)

DRAFT 10/5/09, 11:35 a.m.

Previous ADOR 91-0050

Arizona Form 304 Draft - Enterprise Zone Credit - 2010 Page 4

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