Form Rv-F1319501 - Job Tax Credit For Hiring Persons With Disabilities Business Plan
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2TENNESSEE DEPARTMENT OF REVENUE
FRANCHISE AND EXCISE TAX
JOB TAX CREDIT FOR HIRING PERSONS WITH DISABILITIES BUSINESS PLAN
Taxpayer Name
FEIN/Account Number
Mailing Address
City, State, Zip
1. Newly Created Tennessee Jobs
Fiscal Year
Employee Name
Social
State Employment Incentive
Full
Health Insurance
End
Security
Program
Time
Provided
Number
(Yes/No)
(Yes/No)
2. Tennessee Job Summary
Employment
Fiscal Year End
Workers With Disabilities at
Workers With Disabilities at
Net Increase in
Level
Start of Fiscal Year
End of Fiscal Year
Qualified Jobs
Full Time
Part Time
Total
The statements made on this business plan are true to the best of my
knowledge and belief. (Must be signed by the taxpayer.)
SIGN HERE:
Control No.
Signature and Date
Title
Phone No.
FOR DEPARTMENT OF REVENUE USE ONLY
RV-F1319501 (Rev. 6-12)
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