Form Dr 0074 - Pre-Certification Of Qualified Enterprise Zone Business - Colorado Department Of Revenue Page 2

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*130074==29999*
Section II
All Claimants must complete this information.
Check here if a certification has been filed
Tax Year Ending
(MM/YY)
for this facility in a prior year:
Enterprise Zone
Type of Business (retail, mfg, farm, etc)
Business Name
Address — Actual Location of Facility
Zip
City
State
NAICS code from
Colorado Account Number
SSN or FEIN
Date facility began operations at this location
Business Phone Number
(
)
Did this facility relocate from another Colorado location?
Yes
No
The following information is required regardless of whether or not any jobs credits are being claimed. For statistical
purposes, self-employed owners and partners working in the business should be counted here, even if they do not
qualify as "employees" for other tax purposes.
Number of owners/workers/employees at facility beginning of tax year
Number at end of tax year
Change in total (end of year – beginning)
Number of employees transferred from another Colorado facility owned by taxpayer to this facility
Note: The following section on average compensation is not required if it will reveal the compensation paid to any
individual employee.
Average Annual
Average Hourly
Employee Category
Number of Employees
Compensation including
Compensation including
(as defined by employer)
in category
benefits per employee
benefits per employee
Full-time employees
Part-time employees
Temporary employees
Contract employees
Investment Tax Credit (ITC)
If this was an in-state relocation, no ITC or job training credit is allowed on investment associated with the relocation
unless the new facility meets the criteria in New Business Facility "Qualified Expansion" section (2) below.
Total capital investment in zone during year
$
Capital investment qualifying for ITC during year
$
Amount of 3% EZ Investment Tax Credit claimed
$
Job Training Tax Credit
Number of employees trained
Amount of 10% EZ Job Training Tax Credit claimed
$

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