Jobs And Investment Tax Credit Worksheet For Tax Year 2012

JOBS AND INVESTMENT TAX CREDIT

WORKSHEET FOR TAX YEAR 2012

36 M.R.S.A. § 5215

TAXPAYER NAME: _____________________________________ EIN/SSN: ________________

Note: Owners of pass-through entities (partnerships, LLCs, S corporations, trusts, etc.) making an eligible investment, see

instructions. Enter name and ID number of the entity on the lines below. Also enter your ownership percentage in

the pass-through entity for the tax year.

OWNERSHIP

NAME OF PASS-THROUGH ENTITY

EIN/SSN

PERCENTAGE

_______________________________________________

_______________________

________ %

Part 1

1. 2012 qualifi ed investment attributable to property located in Maine

(must be at least $5,000,000) ........................................................................................................................... 1. ________________

2. Credit claimed. Enter 2012 qualifi ed federal credit (See instructions. The taxpayer must meet the criteria

in Parts 2A & 2B below in order to claim a credit amount on this line.) ............................................................. 2. ________________

3. Carryover from prior years (see instructions) ................................................................................................... 3. ________________

4. Total credit available (add lines 2 and 3). Do not enter more than $500,000. Enter here and

on Form 1120ME, Schedule C, line 29b, or Form 1040ME, Schedule A, line 18 ............................................. 4. ________________

Unused credit amounts may be carried forward for up to 6 years.

VERIFICATION OF JOB CREATION FOR INVESTMENT IN 2012 (See instructions)

Part 2A

5. 2009 unemployment contribution wages .......................................................................................................... 5. ________________

6. 2010 unemployment contribution wages .......................................................................................................... 6. ________________

7. 2011 unemployment contribution wages ......................................................................................................... 7. ________________

8. Enter greatest of lines 5, 6 or 7......................................................................................................................... 8. ________________

9. 2012 unemployment contribution wages (The unemployment compensation may be for 2012, 2013 or

2014 - see instructions) .................................................................................................................................... 9. ________________

10. New jobs credit base. Subtract line 8 from line 9 (You do not qualify for the credit if less than

$1,200,000)...................................................................................................................................................... 10. ________________

Part 2B

11. Date qualifi ed investment placed in service in Maine ..................................................................................... 11. ________________





12. Were there at least 100 new jobs created within two years of the date on line 11? ........................................ 12.

Yes

No

12a. If so, as of what date?.......................................................................................................................... 12a. ________________

Rev. 10/12