Form 72-S - Idaho Hire One Act Credit Supplemental Schedule

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72-S
Idaho Hire One Act Credit Supplemental Schedule
F
O
R
EFO00244
M
09-20-11
Name(s) as shown on return
Social Security Number or EIN
Tax year ending
A
B
C
D
E
F
G
H
I
Gross Wages
Paid to Employee
Health Care
During the
Gross Wages
Gross Wages
Date
Benefit Coverage
Employee's Initial
Reported on
Reported on
Social Security
Date
Employment
County of
(Single 80% or
12 Months of
Form 72,
Form 72,
Employee's Name
Number
Hired
Ceased
Employment
Family 70%)
Employment
Part III, line 1a
Part III, line 1b
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Page _______ of ________

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