Refund Of Taxes Paid To The State Of Texas Page 2

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Form 89-100 (Back)(Rev.9-11/7)
Application for Refund of Taxes Paid for an Eligible Employer of a
Certified Recipient of Temporary Assistance for Needy Families (TANF) or Medicaid
Who may file: Any Employer:
• Who pays eligible taxes that are administered by the Comptroller of Public Accounts;
• Who pays wages during the first year of employment to an employee who is a resident of Texas and was a certified recipient of TANF or Medicaid
any month within 6 months of the start date; and
• Provides and pays for the employee a part of the cost of a HMO health plan, a self-funded or self-insured plan under ERISA, or health benefi t plan
approved by the Commissioner of Insurance.
Note: An employer who requests a refund for wages paid to an employee must provide the same insurance coverage to that employee as is provided to
other employees in their employment.
What taxes can be refunded: The following taxes credited to the general revenue fund paid by the taxpayer may be refunded: state sales and use,
franchise, boat and boat motor, inheritance and/or PUC gross receipts, hotel and/or manufactured housing. An employer may apply for a refund of taxes
paid and postmarked in the same calendar year in which wages are paid to a certifi ed employee.
When to file: The employer may apply for a tax refund for wages paid an employee in a calendar year only on or after January 1 and before April 1 of the
calendar year following the year the taxes/wages were paid. For example: A refund request for wages paid in calendar year 2011 must be submitted on
or after January 1, 2012 but before April 1, 2012.
How to file: After completing all items through Item 30, send the original application to:
Texas Workforce Commission
WOTC/State Tax Refund Unit—Room 202T
101 E. 15th St.
Austin, TX 78778-1442
Properly completed forms postmarked on or after January 1st and before April 1st will be accepted. Incomplete forms will be returned. After receiving
certification from the Texas Workforce Commission, this application will be forwarded to the Comptroller of Public Accounts for further verifi cation and,
if applicable, refund issuance.
Specifi c Instructions
Employer Information
Item 3 - Enter the employer’s Texas taxpayer number. If the employer does not have a taxpayer number for doing business in Texas, enter the
employer’s Federal Employer Identification Number (FEIN). Use the FEIN or Texas taxpayer number associated with the employee’s W-2 form.
Items 4 & 5 - Enter the beginning and ending dates of the period in which the taxes and wages were paid. A separate claim must be filed for each calendar
year. NOTE: The ending date will be the earlier of the employee’s termination date, the employee’s first anniversary date, or the end of the
calendar year.
EXAMPLES:
DATE OF HIRE
WHEN TO FILE
CLAIM BEGIN DATE
CLAIM END DATE
01/01/10
01/01/11 through 03/31/11
01/01/10
12/31/10
06/01/10
01/01/11 through 03/31/11
06/01/10
12/31/10
01/01/12 through 03/31/12
01/01/11
05/31/11
Item 6 - Enter employer’s name.
Item 7 - Enter the street address, city, state, ZIP code of the employer. Also, include a name, telephone number and complete address for a contact
person, if different.
Employee Information / Release Authorization
Items 10, 11, & 12 - Enter the last name, first name and middle initial of the employee who was a recipient of TANF during their first month of employment.
Item 13 - Enter the Social Security number of the employee listed in Items 10-12.
Item 14 - Enter the employment start date of the employee listed in Items 10-12 (MM/DD/YY).
Item 15 - Enter the termination date of the employee (if applicable) in Items 10-12. (MM/DD/YY).
Item 16 - The employee listed in Items 10, 11, 12 & 13 MUST sign here authorizing the Texas Workforce Commission to certify that the employee was
a recipient of financial assistance under TANF or Medicaid any month within 6 months of the beginning date of employment.
Item 17 - Enter date signed.
Refund Calculation
Item 18 - Enter the amount of TOTAL WAGES paid within the first year of employment to the employee during the claim period in Items 4 & 5.
Item 19 - Enter the amount calculated by multiplying the amount in Item 18 by 20%.
Item 21 - If this is the second claim for wages paid to an employee during their first year of employment, enter the refund amount of the fi rst claim.
Item 22 - Enter the difference of Item 20 minus Item 21. A maximum refund of $2,000 may be claimed for each eligible employee. A prior claim fi led for
the same employee reduces the maximum amount allowed on this claim by the amount paid on the prior claim.
Item 23 - Enter the smaller of Item 19 or Item 22. This is the refund you are claiming.
Employer’s Statement Regarding Insurance
Item 24 - Check the block that applies to the type of medical insurance coverage that is paid for and provided to the eligible employee.
Item 25 - Enter name of Health Insurance Provider.
Item 26 - Enter address of Health Insurance Provider.
Item 27 - Enter the group number, if applicable.
Item 28 - Enter the policy number, if applicable, and effective date of the policy.
Item 29 - Enter the telephone number of the Health Insurance Provider.
Item 30 - By signing, the taxpayer/employer certifies that they meet the eligibility requirements listed in the certification. If the form is completed by a
duly authorized agent of the taxpayer/employer, a Power of Attorney or other written authorization must be on file with the Texas Workforce
Commission WOTC/State Tax Refund Unit. Attach a copy of the Power of Attorney or other written authorization to each claim filed.
Item 31 - Signature of authorized TWC employee.
DO NOT SEND THIS FORM TO THE STATE COMPTROLLER
For Tax Refund assistance please call:
Texas Workforce Commission
1-800-695-6879
Comptroller of Public Accounts
1-800-531-5441, ext. 34545 or 512-463-4545
Individuals may receive, review, and correct information that TWC collects about the individual by emailing to
open.records@twc.state.tx.us or writing to TWC Open Records, 101 East 15th St., Rm. 266, Austin, TX 78778-0001.

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