Form 332 Draft - Credit For Healthy Forest Enterprises

Form 332 Draft - Credit For Healthy Forest Enterprises - 2010 Page 4

Name:

TIN:

Qualiﬁ ed Employees of Healthy Forest Enterprise

Form 332-1 (2010)

Complete a Form 332-1 for each qualiﬁ ed employee of the Healthy Forest Enterprise. See instructions for Form 332-1 (included with Instructions

for Form 332, page 3) about providing the requested information in an alternative format.

1 Employee name

2 Employee’s taxpayer identiﬁ cation number (TIN)

3 Did employee reside in Arizona on date of hire?

Yes

4 Brief description of employee’s job duties:

5 Current date of employment

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

7a Is the employee in a permanent full time position?

Yes

7b If the answer to line 7a is yes, list the number of hours the employee worked during the taxable year

7c If the answer to line 7b is less than 1550 hours annually, explain:

8 Employee’s annual compensation for the taxable year $

9a Total cost of health insurance provided by employer for employee. (See instructions.) $

9b Total cost of health insurance for employee paid by employer. (See instructions.) $

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

Yes

11 Check only one box.

ﬁ rst year employee

second year employee

third year employee

ADOR 10683 (10)

DRAFT 10/5/09, 2:25 p.m.

Previous ADOR 91-5497

Form 332 Draft - Credit For Healthy Forest Enterprises - 2010 Page 4