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Certification Form For Issuance Of Prep Tax Credit Certificate - Philadelphia Re-Entry Employment Program ("Prep") Tax Credit

CITY OF PHILADELPHIA – DEPARTMENT OF REVENUE

PHILADELPHIA RE-ENTRY EMPLOYMENT PROGRAM (“PREP”) TAX CREDIT

Certification Form for Issuance of PREP Tax Credit Certificate

Applicant’s Name: _______________________________________________________

Business Address: _______________________________________________________

Philadelphia Business Tax Account Number: _________________________________

Federal Employer Identification Number:

_________________________________

PREP Tax Credit Amount Requested: _________________

(Tax credit calculation details attached)

Certification: To be signed by an authorized representative of the applicant.

The undersigned representative for the applicant hereby certifies the following:

•

A PREP Tax Credit Agreement has been fully executed with the City of

Philadelphia – Department of Revenue.

•

All full-time and part-time employees listed on the attached documents, for which

the PREP Tax Credit is being requested, have been certified by The Mayor’s Office

of Re-Integration Services for Ex-Offenders (“R.I.S.E.”) as “Qualifying Employees”

– “Qualifying Full-Time Employee” or “Qualifying Part-Time Employee”.

•

Each organization listed on the attached document, for which the required

minimum contribution was made and for which the PREP Tax Credit is being

requested, has been certified by R.I.S.E. as a “Qualifying Exempt Organization”.

•

Each Qualifying Employee listed was employed by the business or the Qualifying

Exempt Organization for at least six (6) months.

•

The Revenue Department (“Department”) will be notified within one (1) week after

any Qualifying Employee is no longer employed by the business or by the Qualifying

Exempt Organization.

The taxpayer further certifies that it is maintaining its obligations in accordance

with the terms and conditions of the PREP Tax Credit Agreement executed on the

_______ day of __________ (month, year) and is in compliance with the

Department’s requirements.

I hereby certify that all information contained in this application and the

attachments are true and correct to the best of my knowledge.

Signature of Representative: _______________________________ Date: __________

Print Name of Representative: _____________________________________________

Title of Representative: ___________________________________________________

Representative’s Address: _________________________________________________

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Rev. 9.2010

Certification Form For Issuance Of Prep Tax Credit Certificate - Philadelphia Re-Entry Employment Program ("Prep") Tax Credit