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

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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
STREET
EMPLOYER OR AUTHORIZED REP ONLY:
ADDRESS:__________________________________________________________
All items must be completed and both signatures must be
___________________________________________________________________
present – failure to complete the form is reason for
CITY
ST
ZIP CODE
rejection.
SEX: _____Male _____Female
To be considered for EIP certification processing, the
st
completed form must be MAILED on or before the 21
I hereby certify that:
day following the date that the employee began work.
Forms not meeting this standard will be rejected.
I RECEIVED PENNSYLVANIA CASH ASSISTANCE IN THE GA or TANF
CATEGORY WITHIN THE PAST 12 MONTHS; AND/OR
Certification letters will be issued to the employer by the
Pennsylvania Department of Labor and Industry. The
I AM RECEIVING OR HAVE RECEIVED REHABILITATION SERVICES
employer is responsible for maintaining the certification
THROUGH A STATE REHABILITATION SERVICES PROGRAM OR THE
form. When filing for the EIP Tax Credit, the employer is
VETERANS’ ADMINISTRATION.
required to submit a legible copy of the certification form
with a completed PA Schedule W.
I authorize release of information by the PA Dept. of Public Welfare and/or the state
Office of Voc. Rehab. to the Tax Credit Unit to determine if the following employer is
Rejection letters will be issued to the employer by the
eligible to receive a state tax credit for hiring and retaining me as an employee.
Pennsylvania Department of Labor and Industry and will
indicate the reason for rejection.
__________________________________________________/_________________
Employee Signature
Date
Rejections may be appealed only if the reason for rejection
was not:
EMPLOYER INFORMATION:
Failure to meet the timeliness standard
EMPLOYER
Missing identification information or signature(s)
NAME:_____________________________________________________________
Alteration, defacing, or omission of any part of the
original form
STREET
ADDRESS:__________________________________________________________
After completing the required information, MAIL this
form to:
___________________________________________________________________
CITY
ST
ZIP CODE
TAX CREDIT COORDINATION SERVICES
TH
LABOR & INDUSTRY BUILDING, 13
FLOOR
EMPLOYEE START DATE:__________________________
TH
7
AND FORSTER STREETS
HARRISBURG, PA 17120
FEDERAL EMPLOYER IDENTIFICATION # (FEIN):__________________________
PHONE #: 800-345-2555
EMPLOYER’S AREA CODE AND PHONE #: (
)________________________
AUTHORIZED REP INFORMATION:
(WHEN APPLICABLE)
JOB TITLE_______________________________
______________________________________________
EMPLOYEE’S STARTING HOURLY WAGE $__________
REPRESENTATIVE FIRM NAME
DID THE AVAILABILITY OF THE EIP TAX CREDIT CONTRIBUTE
______________________________________________
TO THE DECISION TO HIRE THIS PERSON?
Yes_____ No_____
STREET ADDRESS
______________________________________________
I CERTIFY THAT THE INFORMATION I HAVE PROVIDED IS ACCURATE:
CITY, STATE, ZIP CODE
___________________________________________________________________
______________________________________________
Signature of Employer/Representative
PHONE NUMBER
___________________________________________________________________
______________________________________________
Name and Title of Employer/Representative (please print clearly)
FAX NUMBER
______________________________________________
REV. 1601(A) (01/06)
E-MAIL ADDRESS

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