Form Dr 0074 - Pre-Certification Of Qualified Enterprise Zone Business - Colorado Department Of Revenue Page 3

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*130074==39999*
New Business Facility Jobs Credit
Number of qualifying new business facility jobs
Were the qualifying employees leased
Yes
No
from another company?
Amount of new business facility jobs tax credit claimed
$
Amount of agricultural processing new business facility jobs tax credit claimed
$
Amount of health insurance new business facility jobs tax credit claimed
$
Enhanced Rural EZ credits:
Qualified County
Enhanced new business facility jobs tax credit claimed
$
Enhanced agricultural processing NBF jobs tax credit claimed
$
To claim new jobs credits, you must qualify under one of the following three criteria
a. Give date facility was established
(MM/DD/YY)
1. If qualifying new business facility:
a. Give date of qualification
(MM/DD/YY)
2. If qualifying expansion new business facility
10 employee increase over preceding
$1,000,000 investment
12 month average
b. Was qualification a result of
10 percent employment increase over
100% investment increase
preceding 12 month average
3. If qualifying replacement new business facility
a. Give date of qualification
(MM/DD/YY)
b. Was qualification a result of
$3,000,000 investment
or
300% investment increase
Taxpayer Signature
I declare that all of the above information is true and correct to the best of my knowledge and belief.
Signature of Authorized Company Official/Owner
Print Name
Date
(MM/DD/YY)
Title
Business Name
Colorado Account Number, FEIN or SSN
Tax preparer or other contact for follow up information (please print)
Fax Number
Phone Number
(
)
(
)
E-mail address
Certification by Zone Administrator
I, the duly authorized administrator of the above-mentioned Enterprise Zone, hereby certify to the State of
Colorado, Department of Revenue that the above named facility is entirely within the designated Enterprise Zone.
Effective Date of Zone for the Location
(MM/DD/YY)
Signature of Zone Administrator
Date
(MM/DD/YY)
For more information about Enterprise Zone, contact the agencies listed below:
Colorado Department of Revenue
Colorado Office of Economic Development
and International Trade
Denver, CO 80261-0005
Phone: 303-238-SERV (7378)
1625 Broadway, Suite 2700
See "FYI" Publications for additional information:
Denver, CO 80202
Phone: 303-892-3840

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