Louisiana Louisiana Youth Jobs Tax Credit Employer Application

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Louisiana Youth Jobs Tax Credit Employer Application
Form R-90004R-90004 (1/24)	

Louisiana Youth Jobs
Tax Credit Employer Application

Email completed applications to:
[email protected]
during application period of
January 1 to February 28.

Louisiana Revised Statute 47:6028

PLEASE PRINT OR TYPE

Applicant Information (To be completed by the employer)
LA Revenue Account Number or SSN

Federal Employer Identification Number

Calendar Year of Application

Date of Application (mm/dd/yyyy)

Legal Name

Trade Name

Address

City

Contact Person Name

State

Email Address

ZIP

Phone Number

Complete the information below for each qualifying youth hired who completed three consecutive months of employment in the calendar
year of application listed in the space provided above. You must also have each qualifying employee complete Form R-90004-B, Louisiana
Youth Jobs Tax Credit Employee Certification, and attach a copy to this application. If additional lines are needed, use Page 2.
Check* if Employed:
Last 4 digits
of SSN

Employee Name

Full-Time

Part -Time

(32 hours
per week)

(20 hours
per week)

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■

■

■

■

■

■

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■

TO BE COMPLETED BY LDR
Credit Amount Approved:

*By checking a box, you attest that the employee is working in a full-time or part-time position that pays wages that are equivalent to the wages paid for similar jobs, with
adjustments for experience and training.

Louisiana Revised Statute 47:1517.1(B)(4) requires the Louisiana Department of Revenue to report on tax incentives that include a job
creation component. All taxpayers claiming the Youth Jobs credit are required to attach a completed Form R-6311, Tax Incentives with Job
Creation Components, to their income tax return. Form R-6311 does not replace documentation required to be submitted for each credit.
Signature and Verification
I attest and affirm that the information submitted herein is true and accurate to the best of my knowledge and acknowledge that a finding of misrepresentation of the
information presented herein will subject myself and/or my employee to legal and tax consequences, including but not limited to recapture of any credits granted on
the basis of such misrepresentation. I further represent that I have exercised due diligence to ensure that all information submitted herein is in compliance with the
requirements of R.S. 47:6028 and LAC 61:I.1921 and agree to maintain substantiating documentation to be produced upon the request of the Department of Revenue.
Signature

Print Name

Date (mm/dd/yyyy)

Title

Telephone Number

FOR OFFICIAL USE ONLY
Total credit amount approved:

Date Application Received (mm/dd/yyyy)

Signature and Title of Department Representative

Date (mm/dd/yyyy)

1

R-90004 (1/24)	

Louisiana Youth Jobs
Tax Credit Employer Application

Email completed applications to:
[email protected]
during application period of
January 1 to February 28.

Louisiana Revised Statute 47:6028

PLEASE PRINT OR TYPE

Check* if Employed:

Employee Name

Last 4 digits
of SSN

Full-Time

Part -Time

(32 hours
per week)

(20 hours
per week)

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■

■

■

■

■

■

■

■

■

■

■

■

■

■

■

■

■

TO BE COMPLETED BY LDR
Credit Amount Approved:

*By checking a box, you attest that the employee is working in a full-time or part-time position that pays wages that are equivalent to the wages paid for similar jobs, with
adjustments for experience and training.

2

Extracted from PDF file 2023-louisiana-form-r-90004.pdf, last modified February 2022

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More about the Louisiana Form R-90004 Individual Income Tax TY 2023

Employees who are eligible and are young between the ages of 16 to 23 may use Form R-90004 to claim Louisiana Youth Jobs Tax Credits

We last updated the Louisiana Youth Jobs Tax Credit Employer Application in February 2024, so this is the latest version of Form R-90004, fully updated for tax year 2023. You can download or print current or past-year PDFs of Form R-90004 directly from TaxFormFinder. You can print other Louisiana tax forms here.

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Other Louisiana Individual Income Tax Forms:

TaxFormFinder has an additional 34 Louisiana income tax forms that you may need, plus all federal income tax forms.

Form Code	Form Name
Form IT-540	Resident Income Tax Return Tax Return
Form 540-ES	Louisiana Estimated Tax Declaration Voucher For Individuals Estimated
Form R-540INS (Obsolete)	Refund Request of LA Citizens for Property Insurance-Individual
Form 540V	Electronic Filing Payment Voucher Voucher
R-1300	Employee Withholding Exemption Certificate (L-4)

Download all LA tax forms View all 35 Louisiana Income Tax Forms

Form Sources:

Louisiana usually releases forms for the current tax year between January and April. We last updated Louisiana Form R-90004 from the Department of Revenue in February 2024.

Show Sources >

About the Individual Income Tax

The IRS and most states collect a personal income tax, which is paid throughout the year via tax withholding or estimated income tax payments.

Most taxpayers are required to file a yearly income tax return in April to both the Internal Revenue Service and their state's revenue department, which will result in either a tax refund of excess withheld income or a tax payment if the withholding does not cover the taxpayer's entire liability. Every taxpayer's situation is different - please consult a CPA or licensed tax preparer to ensure that you are filing the correct tax forms!

Historical Past-Year Versions of Louisiana Form R-90004

We have a total of two past-year versions of Form R-90004 in the TaxFormFinder archives, including for the previous tax year. Download past year versions of this tax form as PDFs here:

2023 Form R-90004

2022 Form R-90004

TaxFormFinder Disclaimer:

While we do our best to keep our list of Louisiana Income Tax Forms up to date and complete, we cannot be held liable for errors or omissions. Is the form on this page out-of-date or not working? Please let us know and we will fix it ASAP.