Pennsylvania Tax Credit Certification Request Form

Tax Credit Certification Request Form
Tax Credit Certification Request Form (REV-1601)
TAX CREDIT CERTIFICATION REQUEST FORM
PENNSYLVANIA EMPLOYMENT INCENTIVE PAYMENT (EIP) PROGRAM

INSTRUCTIONS
ENTRIES ON THIS FORM MUST BE CLEAR AND
LEGIBLE. Other than signatures, entries must be handprinted or typed.

ADDITIONAL INSTRUCTIONS FOR
EMPLOYER OR AUTHORIZED REP ONLY:
All items must be completed and both signatures must be
present – failure to complete the form is reason for
rejection.

NEW EMPLOYEE INFORMATION
SOCIAL SECURITY #:

/

/

NAME:______________________________________________________________
FIRST
MI
LAST
STREET
ADDRESS:__________________________________________________________
___________________________________________________________________
CITY
ST
ZIP CODE
SEX: _____Male _____Female

To be considered for EIP certification processing, the
st
completed form must be MAILED on or before the 21
day following the date that the employee began work.
Forms not meeting this standard will be rejected.
Certification letters will be issued to the employer by the
Pennsylvania Department of Labor and Industry. The
employer is responsible for maintaining the certification
form. When filing for the EIP Tax Credit, the employer is
required to submit a legible copy of the certification form
with a completed PA Schedule W.
Rejection letters will be issued to the employer by the
Pennsylvania Department of Labor and Industry and will
indicate the reason for rejection.
Rejections may be appealed only if the reason for rejection
was not:
ƒ
ƒ
ƒ

Failure to meet the timeliness standard
Missing identification information or signature(s)
Alteration, defacing, or omission of any part of the
original form

After completing the required information, MAIL this
form to:
TAX CREDIT COORDINATION SERVICES
TH
LABOR & INDUSTRY BUILDING, 13 FLOOR
TH
7 AND FORSTER STREETS
HARRISBURG, PA 17120
PHONE #: 800-345-2555
AUTHORIZED REP INFORMATION:
(WHEN APPLICABLE)
______________________________________________
REPRESENTATIVE FIRM NAME
______________________________________________
STREET ADDRESS
______________________________________________
CITY, STATE, ZIP CODE
______________________________________________
PHONE NUMBER
______________________________________________
FAX NUMBER
______________________________________________
E-MAIL ADDRESS

I hereby certify that:
I RECEIVED PENNSYLVANIA CASH ASSISTANCE IN THE GA or TANF
CATEGORY WITHIN THE PAST 12 MONTHS; AND/OR
I AM RECEIVING OR HAVE RECEIVED REHABILITATION SERVICES
THROUGH A STATE REHABILITATION SERVICES PROGRAM OR THE
VETERANS’ ADMINISTRATION.
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
eligible to receive a state tax credit for hiring and retaining me as an employee.
__________________________________________________/_________________
Employee Signature
Date

EMPLOYER INFORMATION:
EMPLOYER
NAME:_____________________________________________________________
STREET
ADDRESS:__________________________________________________________
___________________________________________________________________
CITY
ST
ZIP CODE
EMPLOYEE START DATE:__________________________
FEDERAL EMPLOYER IDENTIFICATION # (FEIN):__________________________
EMPLOYER’S AREA CODE AND PHONE #: (

)________________________

JOB TITLE_______________________________
EMPLOYEE’S STARTING HOURLY WAGE $__________
DID THE AVAILABILITY OF THE EIP TAX CREDIT CONTRIBUTE
TO THE DECISION TO HIRE THIS PERSON?
Yes_____ No_____

I CERTIFY THAT THE INFORMATION I HAVE PROVIDED IS ACCURATE:
___________________________________________________________________
Signature of Employer/Representative
___________________________________________________________________
Name and Title of Employer/Representative (please print clearly)

REV. 1601(A) (01/06)