26 CAR pt. 67, Appendix A
AR1036
TAX CREDIT DOCUMENTATION
Tuition Reimbursement Tax Credit Program
Section A. Tax Year Beginning __ and Ending __
Name of entity: ____________
Address: ______________
City, State, Zip Code: ____________
FEIN/SSN: ___________
SIC CODE: ____________
Eligibility category (see backside, enter a letter A through H) ______.
If category "B" or "D", enter the percentage of your total
Sales that are outside the State of Arkansas __________.
☐ Individual
☐ Partnership (Complete Section C)
☐ Taxable Corporation
☐ LLC (Complete Section C)
☐ Fiduciary
☐ Subchapter-S (Complete Section C)
Section B.
Employee's Name*
Tuition, books, & fees reimbursed to employee ($)
For Term Ending
(date)
Total Amount Reimbursed ______
Total Tax Credit = (total amount reimbursed x (0.30) = ______
*If more space is needed for employees' names, attach addition sheet(s) and enter the total amount reimbursed for all employees in the space immediately above.
Section C.
| Owner's Name* | Percentage of Ownership | Social Security Number | Proportionate Share of Credit* |
|---|---|---|---|
| _____ | _____ | _____ | _____ |
| _____ | _____ | _____ | _____ |
| _____ | _____ | _____ | _____ |
| _____ | _____ | _____ | _____ |
| _____ | _____ | _____ | _____ |
| _____ | _____ | _____ | _____ |
*The credit should be allocated to each member based upon that member's share of the entity's net income and loss. A member's proportionate share is generally equivalent to the member's percentage of ownership in the entity.
Eligibility Categories.