Tax Credit Verification Form - State Of Montana

ADVERTISEMENT

TAX CREDIT VERIFICATION FORM
Employee Name:
Social Security Number:
Hire Date:
Company Name & Location #:
Our company participates in the Work Opportunity Tax Credit Program. Your responses to the following questions will be confidential
and used only to assist us in complying with the requirements of this program. Please answer the following questions:
Date of birth (month, day, year) ______/_____/______
YES
NO Have you received Supplemental Security Income (SSI) benefits within the last 90 days?
YES
NO Are you a Ticket Holder under the Ticket to Work Program?
YES
NO Have you been unemployed for at least the last 27 consecutive weeks and received at least one payment of
unemployment compensation/benefits during that time?
YES
NO Have you received Vocational Rehabilitation Services through a state approved agency or the Department of Veterans
Affairs? If yes, provide the city & state where the benefits were received.
City ______________________
State______________
YES
NO Are you a member of a family that received Food Stamps (SNAP) within the last 6 months?
If yes, provide the name of the primary recipient and the city & state where the benefits were received.
Recipient Name
City ______________________
State______________
YES
NO Are you a member of a family that received Temporary Assistance to Needy Families (TANF) within the last 2 years?
If yes, provide the name of the primary recipient and the city & state where the benefits were received.
Recipient Name
City ______________________ State
______________
YES
NO Have you been convicted of a felony, placed on probation or released from prison for a felony conviction within the last
year? If yes, provide whether it was a federal or state conviction, the conviction and release dates, and State/County of
conviction.
Federal
State
Conviction Date ____/___/____ Release Date ____/___/____ State/County
.
YES
NO Are you a Veteran?
If yes, please provide your discharge date and answer the following questions:
Discharge date
/
/
.
YES
NO
Are you entitled to compensation for a service-connected injury or illness?
YES
NO
Have you been unemployed for more than 4 weeks but less than 6 months within the last year?
YES
NO
Have you been unemployed for more than 6 months within the last year?
I hereby authorize agencies, organizations, or individuals to release the verification of information on this form for the purpose of applying for tax credits
and incentives. This permission is valid until certification is issued.
Employee's Signature:
Date:
Rev. July 2016
•
•
•
•
PO Box 8026
Missoula MT 59807
Phone (800) 451-6277
Fax (800)498-6131

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form Ab-30p - Personal Property Tax Exemption Application Form - State Of Montana Form Ab-30p - Personal Property Tax Exemption Application Form - State Of Montana Financial
Form Rpd-41290 - High-wage Jobs Tax Credit Claim Form - State Of New Mexico Taxation And Revenue Department Form Rpd-41290 - High-wage Jobs Tax Credit Claim Form - State Of New Mexico Taxation And Revenue Department Financial
Form Rpd-41326 - Rural Health Care Practitioner Tax Credit Claim Form - State Of New Mexico Taxation And Revenue Department Form Rpd-41326 - Rural Health Care Practitioner Tax Credit Claim Form - State Of New Mexico Taxation And Revenue Department Financial
Form Rpd-41340 - Blended Biodiesel Fuel Tax Credit Claim Form - State Of New Mexico Taxation And Revenue Department Form Rpd-41340 - Blended Biodiesel Fuel Tax Credit Claim Form - State Of New Mexico Taxation And Revenue Department Financial
Form Rpd-41372 - Veteran Employment Tax Credit Claim Form - State Of New Mexico Taxation And Revenue Department Form Rpd-41372 - Veteran Employment Tax Credit Claim Form - State Of New Mexico Taxation And Revenue Department Financial
Form Rpd-41331 - Alternative Energy Product Manufacturers Tax Credit Claim Form - State Of New Mexico Taxation And Revenue Department Form Rpd-41331 - Alternative Energy Product Manufacturers Tax Credit Claim Form - State Of New Mexico Taxation And Revenue Department Financial
Form Rpd-41282 - Land Conservation Incentives Tax Credit Claim Form - State Of New Mexico Taxation And Revenue Department Form Rpd-41282 - Land Conservation Incentives Tax Credit Claim Form - State Of New Mexico Taxation And Revenue Department Financial
Form Rpd-41329 - Sustainable Building Tax Credit Claim Form - State Of New Mexico Taxation And Revenue Department Form Rpd-41329 - Sustainable Building Tax Credit Claim Form - State Of New Mexico Taxation And Revenue Department Financial
Form Rpd-41361 - Agricultural Biomass Tax Credit Claim Form - State Of New Mexico Taxation And Revenue Department Form Rpd-41361 - Agricultural Biomass Tax Credit Claim Form - State Of New Mexico Taxation And Revenue Department Financial
Form Rpd-41358 - Cancer Clinical Trial Tax Credit Claim Form - State Of New Mexico Taxation And Revenue Department Form Rpd-41358 - Cancer Clinical Trial Tax Credit Claim Form - State Of New Mexico Taxation And Revenue Department Financial

Related Categories

Parent category: Financial
Download
Go