Arizona Form 304 - Enterprise Zone Credit - 2012 Page 4
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1
2
3
4
5Name:
TIN:
Page
of
Form 304-1 (2012)
Employees at Former Enterprise Zone Location
Complete a Form 304-1 for each employee at the former enterprise zone location hired before July 1, 2011, whether or not the
employee is in a qualifi ed employment position. See instructions for Form 304-1 (included with Instructions for Form 304, page 2)
about providing the requested information in an alternative format.
1
Employee name
2
Employee’s taxpayer identifi cation number (TIN)
3
Employee’s residence address
4
What year is this employee?
Second
Third
Fourth or more
5a Is the residence address listed on line 3 inside or outside of a former enterprise zone that is located in the same county
in which the business is located?
inside
outside
5b If the answer on line 5a is inside, list the name of the former enterprise zone in which the employee’s residence address
is located
6
Employee’s residence address AT DATE OF HIRE
7a Is the residence address listed on line 6 inside or outside of a former enterprise zone that is located in the same county
in which the business is located?
inside
outside
7b If the answer on line 7a is inside, list the name of the former enterprise zone in which the employee’s residence address
was located
8
Current date of employment
9a If employee was previously employed by the business, list the previous date of employment. (See instructions.)
9b If employee was previously employed by the business, list the date of separation
10a Is the employee in a permanent full time position?
Yes
No
10b If the answer to line 10a is yes, list the number of hours the employee actually worked during the taxable year (see
instructions)
11a Employee’s annual compensation for the taxable year $
11b Employee’s hourly wage $
/hour
12a Total cost of health insurance provided by employer for employee. (See instructions.) $
12b Total cost of health insurance for employee paid by employer. (See instructions.) $
13a Has this employee been substituted for another employee in a qualifi ed employment position?
Yes
No
13b If answer on line 13a 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
ADOR 10130 (12)
Print 304-1
Clear 304-1
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