Form Eotc-A - Application For West Virginia Economic Opportunity Tax Credit For Investments Placed In Service On Of After January 1, 2003 Page 2
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1
2
3
4
5BUSINESS NAME
IDENTIFICATION NUMBER
Payroll and Employment:
Payroll
Jobs
3. a. Total WV Payroll and Number of Jobs Prior to investment
$
b. Total WV Payroll and Number of Jobs This Tax Year
$
c. Projected WV Payroll and Number of Jobs After 3 Years:
$
d. Jobs Percentage (see Instructions) and Projected Number
of Jobs After 3 Years:
%
e. Median Compensation of New Jobs (Credit Type: High
Technology Manufacturers):
$
f. Minimum Compensation of New Jobs (Credit Type: Other)
$
Percentage of Employees
Average Annual Cost per
Number of New Jobs
Benefits
with the Benefit
Covered
Employee
4. a. Health
%
$
b. Retirement
%
$
c. Other Benefits (Provide Description and Quantities)
%
$
%
$
%
$
%
$
%
$
Business Activity in West Virginia:
5 a. North American Industry Classification System Code (NAICS):
_________________________
b. Narrative Description of Business Activity in West Virginia:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
6. Does the Taxpayer elect to begin the ten (10) year credit period with the next succeeding taxable year?
yes
no
Under penalties of perjury, I declare that I have examined this credit claim form (including accompanying schedules and
statements) and to the best of my knowledge it is true, and complete.
(Signature of Taxpayer
(Name of Taxpayer: Type or Print)
(Title)
(Date)
(Person to Contact Concerning this Return)
(Telephone Number)
(Signature of Preparer other than Taxpayer)
(Address)
(Date)
DO NOT attach the Application to your annual return. Return the completed application to the West Virginia State Tax
Department, P.O. Box 11275, Charleston, WV 25339-1275. If you have any questions or need further information regarding
this application, telephone (304) 558-3333 or toll free to 1-800-WVA-TAXS (1-800-982-8297).
EOTC-1
Page 2 of 2
Rev. 12/11
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