Form Rev-1601(A) - Tax Credit Certification Request Form - 2000

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TAX CREDIT CERTIFICATION REQUEST FORM
PENNSYLVANIA EMPLOYMENT INCENTIVE PAYMENT (EIP) PROGRAM
INSTRUCTIONS
NEW EMPLOYEE INFORMATION
ENTRIES ON THIS FORM MUST BE CLEAR AND
SOCIAL SECURITY #: ________/_____/____________
LEGIBLE. Other than signatures, entries must be hand-
printed or typed.
NAME: ________________________________________________________________
FIRST
MI
LAST
ADDITIONAL INSTRUCTIONS FOR
EMPLOYER OR AUTHORIZED REP ONLY:
STREET ADDRESS: _____________________________________________________
All items must be completed and both signatures must be
________________________________________________________________________
present – failure to complete the form is reason for rejection.
CITY
ST
ZIP CODE
To be considered for EIP certification processing, the
SEX: _____Male _____Female
completed form must be postmarked or faxed on or before
I HAVE BEEN HIRED BY:
st
the 21
day following the date that the employee began
work. Forms not meeting this standard will be rejected.
EMPLOYER NAME: ____________________________________________________
Certification letters will be issued to the employer by the
STREET ADDRESS:
____________________________________________________
Pennsylvania Department of Labor and Industry. The
employer is responsible for maintaining the certification
________________________________________________________________________
form.
CITY
ST
ZIP CODE
START DATE: __________________________
When filing for the EIP Tax Credit, the employer is required
to submit a legible copy of the certification form with a
I hereby certify that:
completed PA Schedule W.
I RECEIVED PENNSYLVANIA CASH ASSISTANCE IN THE GA or TANF
Rejection letters will be issued to the employer by the
CATEGORY WITHIN THE PAST 12 MONTHS; AND/OR
Pennsylvania Department of Labor and Industry and will
indicate the reason for rejection.
I AM RECEIVING OR HAVE RECEIVED REHABILITATION SERVICES
THROUGH A STATE REHABILITATION SERVICES PROGRAM OR THE
Rejections may be appealed only if the reason for rejection
VETERANS’ ADMINISTRATION.
was not:
§
I authorize release of information by the PA Dept. of Public Welfare and/or the state
Failure to meet the timeliness standard
Office of Voc. Rehab. to the Tax Credit Unit to determine if the following employer is
§
Missing, incorrect, or illegible start date information
eligible to receive a state tax credit for hiring and retaining me as an employee.
§
Missing identification information or signature(s)
§
Alteration, defacing, or omission of any part of the
______________________________________________________/_________________
original form
Employee Signature
Date
After completing the required information, mail or fax this
EMPLOYER (OR AUTHORIZED REP):
form to:
TAX CREDIT PROGRAM
TH
LABOR & INDUSTRY BUILDING, 12
FLOOR
PA. CORPORATION TAX FILE BOX # -OR-
TH
7
AND FORSTER STREETS
OWNER’S SOCIAL SECURITY #: _________________________________________
HARRISBURG, PA 17120
FAX #: 717-787-5785
FEDERAL EMPLOYER IDENTIFICATION # (FEIN): _________________________
AUTHORIZED REP INFORMATION:
EMPLOYER’S AREA CODE AND PHONE #: (
)_______________________
(WHEN APPLICABLE)
WORK TYPE (please check one of the following occupation types):
Professional/Technical/Management_____ Clerical/Sales_____
Service_____
______________________________________
REPRESENTATIVE FIRM NAME
Agricultural/Forestry/Fishery_____
Processing_____ Machine Trades_____
________________________________________________
Bench Work_____
Structural_____
Miscellaneous_____
STREET ADDRESS
EMPLOYEE’S STARTING HOURLY WAGE $____________________
________________________________________________
CITY, STATE, ZIP CODE
DID THE AVAILABILITY OF THE EIP TAX CREDIT CONTRIBUTE
TO THE DECISION TO HIRE THIS PERSON?
Yes_____ No_____
________________________________________________
PHONE NUMBER
I CERTIFY THAT THE INFORMATION I HAVE PROVIDED IS ACCURATE:
________________________________________________
________________________________________________________________________
FAX NUMBER
Signature of Employer/Representative
________________________________________________
________________________________________________________________________
E-MAIL ADDRESS
Name and Title of Employer/Representative (please print clearly)
REV-1601(A) (01/00)

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