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Form W-1 (KJC) Page 2
THE REMAINDER OF THIS FORM MUST BE COMPLETED AND SIGNED BY THE CHIEF FINANCIAL OFFICER
1. Total amount of the licensee’s approved tax credit inducement (one-fifth of the
Required Incentive total state and local inducement for KJRA, KIRA, & KJDA projects or one-fourth
Information of the total state and local inducement allowed by KBI) $
2. Date upon which the project was approved.
A licensee claiming a Kentucky 3. Date when the licensee made the first tax credit claim upon the inducement.
Industrial Revitalization Act 4. Tax credits claimed arising from the inducement, for all quarters prior to the
(KIRA), Kentucky Jobs Retention quarter indicated on the first page of this form. $
Act (KJRA), Kentucky Jobs
Development Act (KJDA), or 5. Amount, if any, by which the local inducement has been reduced because the
Kentucky Business Investment licensee has taken part of its state inducement as a credit on its corporate
(KBI) employer withholding income tax. $
occupational tax credit based 6. Tax credit claimed on Form W1-KJC arising from the inducement for the quarter
upon an economic development indicated on the first page of this form. $
inducement arising from an 7. Total remaining occupational tax credits arising from the inducement which the
approved project, pursuant to licensee claims is available to it after recognition of the tax credit claimed for
KRS 154.24, shall file this the quarter indicated on the first page of this form. $
information quarterly with the 8. Base number of employees in Louisville Metro, Kentucky, prior to the approved
Metro Revenue Commission. project and the number of new Louisville Metro jobs upon which the
inducement was calculated.
9. The licensee’s current number of employees at the end of the quarter indicated
on the first page of this form.
IMPORTANT
You must attach a schedule that includes Kentucky residential address, social security number, and gross pay amounts of each employee who, during the quarter
indicated on the first page of this form, was employed by the licensee primarily to work on the approved project and who was subject to Louisville Metro
withholding tax, and upon whose employer tax withholding the tax incentive project was claimed. The attached employee payroll listing substantiates the
amounts reported on lines 1 through 4 of this form.
I hereby certify, under penalty of perjury:
Sign
Here That the activity engaged in by the licensee with respect to which the tax incentive project credit is claimed was during the
quarter indicated on the first page of this form a “service or technology" activity for KJDA, KBI, and KIRA projects and jobs
preserved or created for KJDA, KBI, and KIRA projects within the meaning of KRS 154.26-010 and was the activity as described
at the time the KJDA, KBI, and KIRA projects was approved.
That the licensee either (i) engages in no business in Kentucky other than that of the approved the tax incentive project, or (ii)
keeps an account of receipts of the licensee arising from its approved KJDA, KBI, and KIRA projects as distinct from all other
receipts of the licensee.
That I have examined the above information and that it is true, correct, and complete to the best of my knowledge, and that
this company has met the requirements of the KJDA, KBI, and KIRA projects.
▼ Signature of Chief Financial Officer
▼ Print name of Chief Financial Officer Date
ELECTRONIC FILING:
Register for electronic filing. It is an easy, secure, and convenient way to file and pay taxes on-line. For more information log on to
https://www.metrorevenue.org
MAILING ADDRESS: P.O. BOX 32300, LOUISVILLE, KENTUCKY 40232-2300
Telephone: (502) 574-4860
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