Form 5884-C - Work Opportunity Credit For Qualified Tax-Exempt Organizations Hiring Qualified Veterans

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5884-C

Work Opportunity Credit for Qualified Tax-Exempt

Form

Organizations Hiring Qualified Veterans

OMB No. 1545-2226

(January 2012)

Department of the Treasury

File this form separately; do not attach it to your return.

▶

Internal Revenue Service

Employer identification number

Name (not trade name) shown on Form 941 or other employment tax return

Trade name (if any)

Number, street, and room or suite no. If a P.O. box, see instructions.

City or town, state, and ZIP code

Is the organization a qualified tax-exempt organization (an organization described in section 501(c) and

exempt from tax under section 501(a))? (see instructions) .

Yes

If “Yes,” go to line 2. If “No,” do not file this form; the organization cannot claim this credit.

Check a box to indicate the employment tax return the organization filed to report wages paid to a qualified veteran:

Form 941

Form 941-PR

Form 941-SS

Form 943

Form 943-PR

Form 944 (or 944 (SP))

Form 944-PR

Form 944-SS

Check a box or boxes to indicate the employment tax period for which the organization is claiming this credit (see instructions):

a Check year:

2011

2012

2013

b Check quarter (if applicable):

1: January, February, March

2: April, May, June

3: July, August, September

4: October, November, December

4a See instructions and enter the total qualified first-year wages paid through the

end of the employment tax period indicated on line 3 to all employees certified

as qualified veterans who began working for you on or after November 22,

2011, and who worked for you for at least 400 hours (as of the date you file

this form) .

b Multiply line 4a by 26% (.26)

5a See instructions and enter the total qualified first-year wages paid through the

end of the employment tax period indicated on line 3 to all employees certified

as qualified veterans who began working for you on or after November 22,

2011, and who worked for you for at least 120 hours but fewer than 400 hours

(as of the date you file this form)

b Multiply line 5a by 16.25% (.1625) .

Add lines 4b and 5b

Enter the total amount of credits claimed on line 11 (minus any amounts reported on line 12) of any

Forms 5884-C filed for prior employment tax periods

Note. If line 7 is greater than line 6, skip lines 8 through 11 and go to line 12. Otherwise, go to line 8.

Subtract line 7 from line 6

Enter total taxable social security wages and tips reported on the return indicated on line 2 for the

period indicated on line 3 (see instructions) .

Note. If you filed a corrected return (for example, Form 941-X) for the period indicated on line 3, enter the amount as corrected.

Multiply line 9 by 6.2% (.062)

Credit claimed for the employment tax period indicated on line 3. Enter the smaller of line 8 or line

10. This is the amount that will be refunded to you. Stop here, sign, and mail this form to the address

below .

If line 7 is greater than line 6, subtract line 6 from line 7. This is the amount you owe. Sign and mail

this form to the address below with your payment for this amount

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and

belief, it is true, correct, and complete. Declaration of preparer is based on all information of which preparer has any knowledge.

Daytime telephone number

Sign

Here

Signature of officer

Date

Title

Print/Type preparer’s name

Preparer's signature

Date

PTIN

Paid