Form Jobz1 - Certification Of Job Opportunity Building Zone (Jobz), Compliance With Business Subsidy Agreement (Bsa)

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JOBZ Certifi cation (JOBZ1)
Certifi cation of Job Opportunity Building Zone (JOBZ)
Compliance with Business Subsidy Agreement (BSA)
Qualifi ed businesses: you must complete and fi le by October 15, 2015
Name of qualifi ed business
Taxpayer name (if different from JOBZ business)
JOBZ ID number
Business address in the zone
FEIN
City
State
Zip code
County
Minnesota tax ID number
MN
Taxpayer:
C-Corporation
S-Corporation
Partnership
Individual
Fiduciary
Other (Specify):
Business contact’s name (fi rst, last)
Title
Daytime phone
Email address of qualifi ed business (optional)
Primary parcel ID (if more than one, attach a sheet)
Date of Business subsidy agreement
1 Are you operating in the zone? (If “no,” stop here; sign and submit this form.) . . . . . . . . . . . . . . . . . . . . . . . . . .1
Yes
No
2 Was there a relocation agreement that required you to create a specifi c number of jobs? (If “no,” skip line 3) 2
Yes
No
3 Are you meeting that requirement? (If “no,” attach an explanation.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Yes
No
4 Number of jobs promised in the business subsidy agreement (BSA) . . . . . . . . . . . . . . . 4
5 Number of employees in the JOBZ zone at the time you fi led this form . . . . . . . . . . . . . 5
6 Minimum wage requirement in the BSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
7 Is the above business in compliance with lines 4 and 6 and all other requirements of the BSA? . . . . . . . . . . . .7
Yes
No
(If “no,” attach an explanation)
Businesses that fail to submit this form or businesses that materially misrepresent their compliance with the JOBZ BSA are:
1) permanently disqualifi ed from receiving future JOBZ benefi ts; and 2) subject to repayment of prior benefi ts received.
I declare that this report is correct and complete to the best of my knowledge and belief.
Signature of authorized representative of qualifi ed business
Date
This certifi cation is required to be fi led annually by October 15, as a condition of continuing eligibility for JOBZ benefi ts.
Mail to: Minnesota Revenue
Mail Station 9901
St. Paul, MN 55146-9901
Phone: 651-556-6836
Fax: 651-556-3102

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