Arizona Form 345 - Credit For New Employment - 2012 Page 4
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1
2
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5Name:
TIN:
Page
of
Form 345-1 (2012)
Employees at Business Location
Complete a Form 345-1 for each employee, whether or not the employee is in a qualifi ed employment position. See instructions for
Form 345-1 (beginning on page 2 of the Instructions for Form 345) about providing the requested information in an alternative format.
1 Employee name
2 Employee’s taxpayer identifi cation number (TIN)
3 What year is this employee?
First
Second
Third
Fourth or more
4a Current date of employment
4b Termination date, if the employee was terminated before the end of the taxable year
5a If employee was previously employed by the business, list the previous date of employment. (See instructions.)
5b If employee was previously employed by the business, list the date of separation
5c Did the employee relocate to this state from out of state?
Yes
No
5d If the employee relocated from out of state, enter date of relocation:
6a Is the employee in a permanent position that consists of at least 1750 hours per year?
Yes
No
6b If the answer to line 6a is yes, list the number of hours the employee actually worked during the taxable year (see
instructions)
7 Are the employee’s job duties performed primarily at the location(s) of the business?
Yes
No
8a Employee’s annual compensation for the taxable year $
8b Employee’s hourly wage $
/hour
9a Total cost of health insurance provided by employer for employee. (See instructions.) $
9b Total cost of health insurance for employee paid by employer. (See instructions.) $
10 Is this employee in a new qualifi ed employment position?
Yes
No
11a Has this employee been substituted for another employee in a qualifi ed employment position?
Yes
No
11b If answer on line 11a is yes, list the date of substitution
and indicate whether the individual
is a second year employee or a third year employee. See instructions before answering this question.
Check only one box.
second year employee
third year employee
Print 345-1
ADOR 11150 (12)
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