RPD-41288                   STATE OF NEW MEXICO - TAXATION AND REVENUE DEPARTMENT
Rev. 12/08/2016
                            APPLICATION FOR HIGH-WAGE JOBS TAX CREDIT
Who Must File:
                   An eligible employer files this form annually to apply for a high-wage jobs tax credit for each new high-wage 
economic-based job created on or after July 1, 2004 and before July 1, 2020, occupied during a qualified period beginning 
with the year the new job is created and for three consecutive qualifying periods. The amount of the credit is 10% of wages 
paid to an eligible employee in a high-wage economic-based job for a maximum credit of $12,000 per qualified period. See the 
instructions for important definitions. For the status of an application or to speak with an auditor, call (505) 841-2986 or  
(505) 841-6486.
  Name of eligible employer                                               New Mexico CRS identification number 

 Physical address                                        City, state, and ZIP code

 Mailing address                                         City, state, and ZIP code

 Name of contact                                         Phone number                          Email address

Total High-Wage Jobs Tax Credit 

1.  Claimed qualifying period(s) for the calendar year: January 1 to December 31, _____________ (year)
2.  Enter the total number of eligible employees occupying a qualifying high-wage job in a
 qualified period included in this application. Refer to the number of employees reported
                  Employee Eligibility Detail Report
 in RPD-41376,                                         .
                                                                                      
3.  Enter the total high-wage jobs tax credit claimed (from column AC of RPD-41376, 
         Employee Eligibility Detail Report                                             $
                                ).
NOTE                                                                          Employee Eligibility Detail Report 
 : Attach the following required documents to this application—RPD-41376,                                                    and all 
supporting documentation including payroll registers, sales documentation for the last 12 months, proof of newly created jobs 
for individuals claimed, and proof of maintaining increase of high-wage jobs for the qualifying period. You can download  
                 Employee Eligibility Detail Report, 
RPD-41376,                                           from our website at www.tax.newmexico.gov. Instead of sending attachments, 
you may contact an auditor for a link to email the documents using a secure application.

 Under penalty of perjury and subject to the applicable penalty outlined in Section 7-9G-1(L) NMSA 1978, I declare 
 that I have examined this claim, and to the best of my knowledge and belief it is true, correct, and complete.   

 Signature of claimant                                                    Date

 Subscribed and sworn before me this                    day of                                                           , 20

 Notary Public                                                           My commission expires 

                                                     FOR DEPARTMENT USE ONLY

 Authorized by the New Mexico Taxation and Revenue Department.

 Approved by:                                                             Title:

 Phone number:                                                            Date:

 High-wage jobs tax credit amount approved:          $                    Claim number:

RPD-41288                                         STATE OF NEW MEXICO
Rev. 12/08/2016
                                          TAXATION AND REVENUE DEPARTMENT
                   APPLICATION FOR HIGH-WAGE JOBS TAX CREDIT
                                                   INSTRUCTIONS
                                                                                                                Page 1 of 6

AMENDMENTS APPLICABLE TO APPLICATIONS FILED                      HOW TO APPLY
WITH TRD ON OR AFTER jANUARY 1, 2017                                                         Application for High-Wage Jobs 
                                                                 Complete Form RPD-41288, 
Section 7-9G-1(L) NMSA 1978. Any person who willfully            Tax Credit. 
                                                                             Then submit it to the Taxation and Revenue 
                                                                                                  Employee Eligibility 
submits a false, incorrect, or fraudulent certification required Department along with RPD-41376, 
pursuant to Section 7-9G-1(K) NMSA 1978 shall be subject         Detail Report
                                                                               and all supporting documentation in 
to all applicable penalties under the Tax Administration Act,    electronic format—payroll registers, sales documentation 
except that the amount on which the penalty is based shall       for the last 12 months, proof of newly created jobs for the 
be the total amount of credit requested on the application for   positions claimed, and proof of increase of high-wage jobs 
                                                                                                                          
approval.                                                        for the qualifying period. The High-Wage Jobs Tax Credit
                                                                                   Employee Eligibility Detail Report, 
                                                                 Form RPD-41376,                                       is an 
The amended text adds several provisions to the statute.         Excel spreadsheet. The report's instructions begin on  
If the taxpayer ceases business operations in New Mexico         page 3 of these instructions. 
while an application for credit approval is pending or after an 
application for credit is approved for any qualifying period     Important: 
                                                                             A taxpayer must apply for approval of the credit 
                                                                                                  but not later than 12 
for a new high-wage economic-based job, the Department           after the close of a qualifying period, 
shall not grant an additional high-wage jobs tax credit to       months following the end of the calendar year in which the 
that taxpayer, except as provided in Section 7-9G-1(O) NMSA      taxpayer's final qualifying period closes
                                                                                                          . 
1978, and shall extinguish any amount of credit approved 
for that taxpayer not already claimed against the taxpayer's     On this application, answer the questions establishing 
modified combined tax liability.                                 that you retain the status of an eligible employer. The 
                                                                 Department may approve the credit and issue to the 
Section 7-9G-1(O) NMSA 1978 states a taxpayer that has           applicant a document granting the tax credit. For status of 
received a high-wage jobs tax credit shall not submit a new      the application, call (505) 841-2986 or (505) 841-6486.   
application for a credit for a minimum of five calendar years 
                                                                 FORM INSTRUCTIONS
from the closing date of the last qualifying period for which 
the taxpayer received the credit if the taxpayer:                1.  Complete all information requested in the address 
(1) lost eligibility to claim a tax credit from a previous          block. 
application pursuant to Section 7-9G-1(E) or (N) NMSA 1978,      2. Line 1. Enter the year of the credit period.
or                                                               3. Line 2. Enter the number of eligible employees 
(2) reduces its total full-time employees in New Mexico             occupying a qualifying high-wage job in the qualified 
by more than five percent after the date on which the last          period included in this application. Refer to the number 
                                                                                                  Employee Eligibility 
qualifying period on the taxpayer's previous application            of entries on Form RPD-41376, 
                                                                    Detail Report
ends.                                                                            .  
                                                                 4.  Line 3. Enter the total high-wage jobs tax credit claimed 
Section 7-1-68(D)(7) NMSA 1978. No interest will be paid            from column AC of RPD-41376. A maximum credit of 
on any high-wage jobs tax credit amount refunded (Section           $12,000 of wages and benefits paid for each high-wage 
7-1-68 NMSA 1978).                                                  job in each qualified period is allowed. 
                                                                                       Application for High-Wage Jobs Tax 
                                                                 Make sure RPD-41288, 
PURPOSE                                                          Credit, 
                                                                         is signed and notarized. Mail this application along 
                                                                                 Employee Eligibility Detail Report, 
The purpose of the high-wage jobs tax credit is to provide       with RPD-41376,                                     and all 
an incentive for urban and rural businesses to create and fill   of the supporting documentation to: Taxation and Revenue 
new high-wage jobs in New Mexico.                                Department, Director's Office, P. O. Box 8485, Albuquerque, 
                                                                 NM 87198-8485. The Department will notify you when the 
The high-wage jobs tax credit may be claimed by an               application is approved. After approval, complete  
                                                                             High-Wage Jobs Tax Credit Claim Form
eligible employer for each new high-wage economic-based          RPD-41290,                                     , to claim 
job performed for the year in which the new high-wage            the credit against the modified combined tax liability due. 
                                                                          Modified combined tax liability
economic job is created and for the three consecutive            (See the                                    definition on 
qualifying periods. A taxpayer must apply for approval of the    page 3 of these instructions.) The Department will refund 
                                          but not later than 
credit after the close of a qualifying period,                   any excess credit.
12 months following the end of the calendar year in which the 
taxpayer's final qualifying period closes                        USING THE HIGH-WAGE JOBS TAX CREDIT
                                  . 
                                                                 When approved, the high-wage jobs tax credit may be 

RPD-41288                                          STATE OF NEW MEXICO
Rev. 12/08/2016
                                       TAXATION AND REVENUE DEPARTMENT
                          APPLICATION FOR HIGH-WAGE JOBS TAX CREDIT
                                                     INSTRUCTIONS
                                                                                                       Page 2 of 6

applied against the modified combined tax liability of a      The qualified job must be occupied for at least 48 weeks 
taxpayer.                                                     during a qualifying period, and an eligible employee must 
                                                              be paid at least $40,000 if the job is performed or based:
To claim approved credits against tax liabilities, submit     • in or within 10 miles of the external boundary of 
               High-Wage Jobs Tax Credit Claim Form, 
RPD-41290,                                           with the   Albuquerque, Las Cruces, Rio Rancho, or the city of 
tax or surcharge return to which you want to apply the          Santa Fe, or 
credit. You may apply the credit against tax owed on 
Form CRS-1, less local option gross receipts taxes; RPD-      • in the county of Los Alamos, 
       Enhanced 911 Services Surcharge;
41114,                                  or RPD-41116,         and $28,000 if the job is performed or based anywhere else 
Telecommunications Relay Service Surcharge                    in the state. 
                                             . When applying 
the credit to Form CRS-1, you must pay any gross receipts     For a new high-wage economic-based job created on or 
tax due over the state rate of 5.125%. The Department will    after July 1, 2015: 
refund any excess credit. 
                                                                a. $60,000 if the job is performed or based in or 
DEFINITIONS                                                        within 10 miles of the external boundaries of a 
                
   eligible employer 
An                   is an employer that:                          municipality with a population of 60,000 or more 
   a.   sold and delivered more than fifty percent of its          according to the most recent federal decennial 
goods produced in New Mexico or non-retail services                census or in a class H county; and 
performed in New Mexico to persons outside New Mexico           b. $40,000 if the job is performed or based in a 
for use or resale outside New Mexico during the applicable         municipality with a population of less than 60,000 
qualifying period, provided that the fifty percent of those        according to the most recent federal decennial 
goods or services is measured by the eligible employer's           census or in the unincorporated area, that is not 
gross receipts;                                                    within 10 miles of the external boundaries of a 
                                                                   municipality with a population of 60,000 or more, 
   b.   is receiving or is eligible to receive development 
                                                                   of a county other than a class H county. 
training program assistance pursuant to Section 21-19-7 
NMSA 1978 during the applicable qualifying period; and        The qualified job must be occupied for at least 48 weeks 
                                                              during a qualifying period, and an eligible employee must 
   c.  whose principal business activities at the location 
                                                              be paid at least $60,000 if the job is performed or based:
in New Mexico for which the high-wage jobs tax credit is 
being claimed consist of manufacturing or performing          • in or within 10 miles of the external boundary of 
non-retail services during the applicable qualifying period.    Albuquerque, Las Cruces, Rio Rancho, or the city of 
                                                                Santa Fe, or 
  new high-wage economic-based job 
A                                      means a job created    • in the county of Los Alamos,
in New Mexico by an eligible employer on or after July 1,     and $40,000 if the job is performed or based anywhere else 
2004 and prior to July 1, 2020, that is occupied for at least in the state. 
48 weeks of a qualifying period by an eligible employee who 
is paid wages calculated for the qualifying period to be at   The high-wage jobs tax credit may be claimed by an 
least:                                                        eligible employer for each new high-wage economic-based 
For a new high-wage economic-based job created prior          job performed for the year in which the new high-wage 
to July 1, 2015:                                              economic-based job is created and for the three consecutive 
                                                              qualifying periods. 
   a.     $40,000 if the job is performed or based in or 
          within 10 miles of the external boundaries of a     A new high-wage economic-based job shall not be eligible 
          municipality with a population of 60,000 or more    for a credit pursuant to this section for the initial qualifying 
          according to the most recent federal decennial      period unless the eligible employer's total number of 
          census or in a class H county; and                  employees with threshold jobs on the last day of the 
   b.  $28,000 if the job is performed or based in a          initial qualifying period at the location at which the job is 
          municipality with a population of less than 60,000  performed or based is at least one more than the number 
          according to the most recent federal decennial      of threshold jobs on the day prior to the date the new 
          census or in the unincorporated area, that is not   high-wage economic-based job was created.
          within 10 miles of the external boundaries of  a 
          municipality with a population of 60,000 or more,   A new high-wage economic-based job shall not be eligible for 
          of a county other than a class H county;            a credit pursuant to this section for a consecutive qualifying 

RPD-41288                                         STATE OF NEW MEXICO
Rev. 12/08/2016
                                      TAXATION AND REVENUE DEPARTMENT
                           APPLICATION FOR HIGH-WAGE JOBS TAX CREDIT
                                                      INSTRUCTIONS
                                                                                                             Page 3 of 6

                                                                                                     does not
period unless the total number of threshold jobs at a location    of New Mexico.  Eligible employee           include an 
at which the job is performed or based on the last day of that    individual who:
qualifying period is greater than or equal to the number of       a.  bears any of the relationships described in 
threshold jobs at that same location on the last day of the       Paragraph (1) through (8) of 26 U.S.C. Section 152(a) to the 
initial qualifying period for the new high-wage                   employer or if the employer is a corporation to an individual 
economic-based job.                                               who owns, directly or indirectly, more than 50% in value of 
                                                                  the outstanding stock of the corporation or, if the employer 
A new high-wage economic-based job shall not be eligible for      is an entity other than a corporation to an individual who 
a credit pursuant to this section if:                             owns, directly or indirectly, more than 50% of the capital 
1.  the new high-wage economic-based job is created due           and profits interest in the entity;
to a business merger or acquisition or other change in            b.  if the employer is an estate or trust; is a grantor, 
business organization;                                            beneficiary, or fiduciary of the estate or trust; or is an 
2.  the eligible employee was terminated from employment          individual who bears any of the relationships described in 
in New Mexico by another employer involved in the                 Paragraphs (1) through (8) of 26 U.S.C. Section 152(a) to a 
business merger or acquisition or other change in                 grantor, beneficiary, or fiduciary of the estate or trust;
business organization with the taxpayer; and                      c.  is a dependent, as that term is described in 26 
3.  the new high-wage economic-based job is performed by:         U.S.C. Section 152(a)(9), of the employer or if the taxpayer 
a.  the person who performed the job or its                       is a corporation of an individual who owns, directly or 
          functional equivalent prior to the business             indirectly, more than 50% in value of the outstanding stock 
          merger or acquisition or other change in business       of the corporation, or if the employer is an entity other 
          organization; or                                        than a corporation, of an individual who owns, directly or 
                                                                  indirectly, more than 50% of the capital and profits interest 
b.  a person replacing the person who performed the 
                                                                  in the entity, or if the employer is an estate or trust of a 
          job or its functional equivalent prior to a business 
                                                                  grantor, beneficiary, or fiduciary of the estate or trust; or
          merger or acquisition or other change in business 
          organization.                                           d.  is working or has worked as an employee or as 
                                                                  an independent contractor for an entity that, directly 
If, however, a new high-wage economic-based job was created       or indirectly, owns stock in a corporation of the eligible 
by another employer and for which an application for the          employer or other interest of the eligible employer that 
high-wage jobs tax credit was received and is under review by     represents 50% or more of the total voting power of that 
the Taxation and Revenue Department prior to the time of the      entity or has a value equal to 50% or more of the capital and 
business merger or acquisition or other change in business        profits interest in the entity.
organization, the employer shall remain eligible for the          Resident
                                                                          means a natural person whose domicile is in New 
high-wage jobs tax credit for the balance of the qualifying 
                                                                  Mexico at the time of hire or within 180 days of the date of 
periods. The new employer that results from a business 
                                                                  hire.  
merger or acquisition or other change in business 
organization may only claim the high-wage jobs tax credit for     Domicile
                                                                           means the sole place where an individual has 
the balance of the qualifying period for which the qualifying     a true, fixed, permanent home. It is the place where the 
job is otherwise eligible.                                        individual has a voluntary, fixed habitation of self and family 
                                                                  with the intention of making a permanent home. 
A job shall not be eligible for a credit pursuant to this section 
if the job is created due to an eligible employer entering        Qualifying period 
                                                                                    means the 12 months beginning on the 
into a contract or becoming a subcontractor to a contract 
                                                                  day an eligible employee begins working in a new high-wage 
with a governmental entity that replaces one or more 
                                                                  economic-based job, or 12 months beginning on the 
entities performing functionally equivalent services for 
                                                                  anniversary of the day an eligible employee began working 
the governmental entity unless the job is a new high-wage 
                                                                  in a new high-wage economic-based job.
economic-based job that was not performed by an employee 
of the replaced entity.                                           Wages 
                                                                         means all compensation paid by an eligible employer 
Eligible employee                                                 to an eligible employee through the employer's payroll 
                means an individual who is employed in 
New Mexico by an eligible employer and who is a resident          system, including those wages that the employee elects to 

RPD-41288                                          STATE OF NEW MEXICO
Rev. 12/08/2016
                                TAXATION AND REVENUE DEPARTMENT
                     APPLICATION FOR HIGH-WAGE JOBS TAX CREDIT
                                                   INSTRUCTIONS
                                                                                                  Page 4 of 6

defer or redirect or the employee's contribution to a 401(k)   at the same time and in the same manner as the gross 
or cafeteria plan program, but wages does not include          receipts tax, such as the compensating tax, the withholding 
benefits or the employer's share of payroll taxes.             tax, the interstate telecommunications gross receipts tax, 
Benefits                                                       and the surcharges imposed by Section 63-9D-5 NMSA 1978 
          means all remuneration for work performed            and the surcharge imposed by Section 63-9F-11 NMSA 1978, 
that is provided to an employee in whole or in part by the     minus the amount of any credit other than the high-wage 
employer, other than wages, including insurance programs,      jobs tax credit applied against any or all of these taxes or 
health care, medical, dental and vision plans, life insurance, surcharges; but modified combined tax liability excludes 
employer contributions to pensions, such as a 401(k), and      all amounts collected with respect to local option gross 
employer-provided services such as childcare offered by        receipts taxes.
an employer to the employee. Benefits does not include the 
                                                               Certification for Job Training Incentive Program (JTIP) 
employer's share of payroll taxes, social security, medicare 
                                                               assistance. 
contributions, federal or state unemployment insurance                     If you are certified for JTIP assistance, you 
contributions, or workers' compensation.                       may also qualify as an eligible employer for purposes of the 
Modified combined tax liability                                high-wage jobs tax credit. For information on becoming 
                                means the total liability      certified for JTIP assistance, visit the New Mexico Economic 
for the reporting period for the gross receipts tax imposed    Development Department's web page, www.gonm.biz, or call 
by Section 7-9-4 NMSA 1978 together with any tax collected     (800) 374-3061.

RPD-41288                                          STATE OF NEW MEXICO
Rev. 12/08/2016
                                       TAXATION AND REVENUE DEPARTMENT
                                      HIGH-WAGE JOBS TAX CREDIT
                           RPD-41376, EMPLOYEE ELIGIBILITY DETAIL REPORT
                                                          INSTRUCTIONS                                       Page 5 of 6

               Employee Eligibility Detail Report,             Column L
RPD-41376,                                         must                 : Enter the position title.
                                        Application 
accompany your submission of RPD-41288,                        Column M
for High-Wage Jobs Tax Credit                                           : Enter the position number. You can choose 
                              , to the New Mexico Taxation 
                                                               any numeric characters, which must remain the same for 
and Revenue Department. You can download RPD-41376, 
Employee Eligibility Detail Report,                            purposes of reporting this high-wage job. The number must 
                                    from our website at www.
                                                               be unique to the position and separate from the employee 
tax.newmexico.gov. Complete all information requested on 
                                                               occupying the position.
the form and attach the form to the application along with 
the other required documents. See the column instructions      Column N
                                                                        : Enter the date the qualifying position was 
listed next.                                                   created. Use the date format mm/dd/ccyy. The job must be 
                                                               created on or after 07/01/2004 and prior to 07/01/2020.
COLUMNS A THROUGH G
                                                               Columns O and P
You only need to enter the data in columns A through G                          : Enter the beginning and ending date of 
once.                                                          the qualifying period included in this application. Use the 
      When you enter the employee's last name in column                                                      Qualifying 
                                                               date format mm/dd/ccyy. See the definition of 
H, subsequent rows self-populate with the information          period
                                                                      on page 3.
provided in the first row. Make sure the information in these 
rows matches the information for the eligible employer on      Column Q
                                                                        : Enter the number of qualified periods previously 
               Application for High-Wage Jobs Tax Credit
RPD-41288,                                                .    claimed for this position. The high-wage jobs tax credit 
                                                               is limited to the year the position was created and three 
Column A
               : Enter the name of the eligible employer.      consecutive qualifying periods for each job.
Column B                                                       Column R
          : Enter employer's New Mexico CRS identification              : Enter the number of weeks the job was occupied 
number.                                                        during the qualifying period by the employee filling the 
Column C                                                       position.
          : Enter employer's Federal Employer Identification 
Number (FEIN).                                                 Column S
                                                                        : Enter the total number of employees with   
                                                                                          day prior
Column D               yes no                                  high-wage positions on the           to the day the position 
               : Enter  or  if the applicant employer sold 
                                                               was created.
and delivered more than 50% of its goods produced in New 
                                                               Column T
Mexico or non-retail services performed in New Mexico to                : Enter the total number of employees with   
                                                                                          last day
persons outside New Mexico for use or resale outside New       high-wage positions on the           of the current qualifying 
Mexico during the applicable qualifying period, provided       period. For each new qualified  high-wage job, the number of  
that the 50% of those goods or services is measured by the     high-wage jobs must be at least one more than the number of  
eligible employer's gross receipts.                            high-wage jobs employed on the day prior to the day the job 
Column E          yes      no                                  was created.
          : Enter       or  if the applicant employer is 
                                                               Column U         yes
receiving or is eligible to receive development training                : Enter     if the employee was paid $40,000 
program assistance pursuant to Section 21-19-8 NMSA 1978.      or more in taxable wages, the job is created prior to July 
Column F          yes      no                                  1, 2015, and the position was located in one of the areas 
          : Enter       or  if the employer has been involved                                 Areas For Columns U 
                                                               described in the next section, 
in a merger or acquisition between January 1, 2004 and the     Through X
                                                                        , during the qualifying period. Otherwise, enter 
date of the application.                                       no
                                                               . 
Column G                              Application for the 
          : Enter the date RPD-41288,                          Column V         yes
High-Wage Jobs Tax Credit                                               : Enter     if the employee was paid $28,000 or 
                           , that included this position, was 
                                                               more in taxable wages, the job is created prior to July 1, 
signed. Use the date format mm/dd/ccyy.
                                                               2015, and the position was located in an area in New Mexico 
COLUMNS H THROUGH AC                                           other than one of the areas described in the next section, 
                                                               Areas For Columns U Through X
Columns H-J                                                                                   , during the qualifying 
               : Enter the name (last name, first name, middle                          no
                                                               period. Otherwise, enter   .
initial) of the employee who is filling the position. If more  Column W
than one employee occupied the qualifying job during the                : For jobs created on or after July 1, 2015, enter 
                                                               yes
qualifying period, complete a separate row for each eligible      if the employee was paid $60,000 or more in taxable 
employee.                                                      wages, and the position was located in one of the areas 
                                                                                              Areas For Columns U 
Column K                                                       described in the next section, 
               : Enter the employee's social security number.  Through X
                                                                        , during the qualifying period. Otherwise, enter 
                                                               no
                                                               .

RPD-41288                                  STATE OF NEW MEXICO
Rev. 12/08/2016
                                   TAXATION AND REVENUE DEPARTMENT
                                   HIGH-WAGE JOBS TAX CREDIT
                      RPD-41376, EMPLOYEE ELIGIBILITY DETAIL REPORT
                                                     INSTRUCTIONS                                              Page 6 of 6

Column X                                              yes          Column AA
               : For jobs created on or after July 1, 2015, enter           : Enter the taxable wages and employer paid 
if the employee was paid $40,000 or more in taxable wages,         benefits paid during the qualifying period (the sum of 
and the position was located in an area in New Mexico other        column Y and column Z). 
                                                     Areas 
than one of the areas described in the next section,               Column AB
For Columns U Through X                                                     : Multiply column AA by 10% and enter it. 
                        , during the qualifying period. 
                 no                                                Column AC
Otherwise, enter .                                                          : Enter the lesser of column AB or $12,000. This 
                                                                   is the amount of  high-wage job tax credit claimed for this 
Areas For Columns U Through X                                      position during the qualifying period. If more than one 
                                   
Municipalities with a population of 60,000 thousand or more        qualified employee occupied this job during this period, 
according to the most recent federal decennial census or a         adjust the amount so that the total credit claimed for all 
class H county:                                                    qualified employees during this period does not exceed 
• in or within 10 miles of the external boundry of                 $12,000. (Enter this amount on Line 2 of RPD-41288, 
                                                                   Application for High-Wage Jobs Tax Credit
  Albuquerque, Las Cruces, Rio Rancho, or the city of                                                       .) 
  Santa Fe, or 
                                                                   IMPORTANT: 
                                                                              Submit all required documentation along 
• in the county of Los Alamos                                                      Application for High-Wage Jobs Tax Credit
                                                                   with RPD-41288,                                             . 
Column Y
          : Enter the gross wages paid during the qualifying       The Department may require you to furnish additional 
period. Do not include benefits paid by the employer or the        documentation to verify eligibility.
employer's share of payroll taxes.
                                                                   COLUMNS AD THROUGH AF
Column Z              employer paid
          : Enter the               benefits paid during 
                                                                   Do not enter any information in columns AD through AF. 
the qualifying period. Do not include the employer's share of 
                                                                   These columns are for Department use only. 
payroll taxes.