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TAX CREDIT CERTIFICATION REQUEST FORM
PENNSYLVANIA EMPLOYMENT INCENTIVE PAYMENT (EIP) PROGRAM
INSTRUCTIONS NEW EMPLOYEE INFORMATION
ENTRIES ON THIS FORM MUST BE CLEAR AND SOCIAL SECURITY #: / /
LEGIBLE. Other than signatures, entries must be hand-
printed or typed. NAME:______________________________________________________________
FIRST MI LAST
ADDITIONAL INSTRUCTIONS FOR STREET
EMPLOYER OR AUTHORIZED REP ONLY: ADDRESS:__________________________________________________________
All items must be completed and both signatures must be ___________________________________________________________________
present – failure to complete the form is reason for CITY ST ZIP CODE
rejection.
SEX: _____Male _____Female
To be considered for EIP certification processing, the st
completed form must be MAILED on or before the 21 I hereby certify that:
day following the date that the employee began work.
Forms not meeting this standard will be rejected. I RECEIVED PENNSYLVANIA CASH ASSISTANCE IN THE GA or TANF
CATEGORY WITHIN THE PAST 12 MONTHS; AND/OR
Certification letters will be issued to the employer by the
Pennsylvania Department of Labor and Industry. The I AM RECEIVING OR HAVE RECEIVED REHABILITATION SERVICES
employer is responsible for maintaining the certification THROUGH A STATE REHABILITATION SERVICES PROGRAM OR THE
form. When filing for the EIP Tax Credit, the employer is VETERANS’ ADMINISTRATION.
required to submit a legible copy of the certification form
with a completed PA Schedule W. I authorize release of information by the PA Dept. of Public Welfare and/or the state
Office of Voc. Rehab. to the Tax Credit Unit to determine if the following employer is
Rejection letters will be issued to the employer by the eligible to receive a state tax credit for hiring and retaining me as an employee.
Pennsylvania Department of Labor and Industry and will
indicate the reason for rejection. __________________________________________________/_________________
Employee Signature Date
Rejections may be appealed only if the reason for rejection
was not: EMPLOYER INFORMATION:
Failure to meet the timeliness standard EMPLOYER
Missing identification information or signature(s) NAME:_____________________________________________________________
Alteration, defacing, or omission of any part of the
original form STREET
ADDRESS:__________________________________________________________
After completing the required information, MAIL this
form to: ___________________________________________________________________
CITY ST ZIP CODE
TAX CREDIT COORDINATION SERVICESTH
LABOR & INDUSTRYTH BUILDING, 13 FLOOR EMPLOYEE START DATE:__________________________
7 AND FORSTER STREETS
HARRISBURG, PA 17120 FEDERAL EMPLOYER IDENTIFICATION # (FEIN):__________________________
PHONE #: 800-345-2555
EMPLOYER’S AREA CODE AND PHONE #: ( )________________________
AUTHORIZED REP INFORMATION:
(WHEN APPLICABLE) JOB TITLE_______________________________
______________________________________________ EMPLOYEE’S STARTING HOURLY WAGE $__________
REPRESENTATIVE FIRM NAME
DID THE AVAILABILITY OF THE EIP TAX CREDIT CONTRIBUTE
______________________________________________ TO THE DECISION TO HIRE THIS PERSON? Yes_____ No_____
STREET ADDRESS
______________________________________________ I CERTIFY THAT THE INFORMATION I HAVE PROVIDED IS ACCURATE:
CITY, STATE, ZIP CODE
___________________________________________________________________
______________________________________________ Signature of Employer/Representative
PHONE NUMBER
___________________________________________________________________
______________________________________________ Name and Title of Employer/Representative (please print clearly)
FAX NUMBER
______________________________________________ REV. 1601(A) (01/06)
E-MAIL ADDRESS
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