The document is an application for an Iowa Wage-Benefits Tax Credit provided by the Iowa Department of Revenue. The tax credit is available to non-retail and non-service businesses that create new full-time jobs in Iowa filled by Iowa residents for at least 12 months. The credit amount is 5% of wages and benefits if the new job pays 130-160% of the county average wage, or 10% if it pays over 160% of the county average wage. The application requests information about the business and each new job in order to determine eligibility for the tax credit, which is issued on a first-come first-served basis up to $10 million annually.

1. Iowa Department of Revenue
www.state.ia.us/tax Application for Iowa Wage-Benefits Tax Credit
1. Name of Business:
2. Address of Business:
3. City, State, Zip Code:
4. Tax Identification Number of Business:
5. Description of the Activities of the Business:
6. If the business is not engaged in the sale of tangible personal property, indicate the portion of your Iowa
sales which currently are derived from business outside Iowa.
7. The type of tax for which the credit will be applied:
8. Does the business file a consolidated tax return under a different tax ID number?
If yes, please provide that tax ID number:
9. If the business is a partnership, limited liability company, S corporation, or estate or trust, please provide
the following information for each partner, member, shareholder or beneficiary. A separate schedule may
be attached.
Name:
Address:
Tax Identification Number:
Pro Rata share of earnings from the Business:
10. For each job for which the credit is claimed, please provide the following. A separate schedule may be
attached.
Name of Employee:
Job Title of Employee:
Address and State of Residence of Employee:
Social Security Number of Employee:
Date that the Employee began work:
County where the Employee works:
Amount of wages paid for the previous 12 months:
Amount of benefits paid for the previous 12 months:
Amount of credit being claimed:
Indicate whether the job is new or retained:
Contact Person: Telephone Number:
Date: E-Mail Address:
This completed application is considered tax return information and is confidential
in accordance with Iowa Code sections 422.20 and 422.72.
42-011a (9/24/07)

2. Iowa Department of Revenue
www.state.ia.us/tax Application for Iowa Wage-Benefits Tax Credit

3. GENERAL INFORMATION
House File 868, adopted by the Iowa Legislature in 2005, provides for a wage-benefits tax credit for a non-
retail, non-service business which creates new jobs related to the location or expansion of the business in
Iowa.
The new job:
 must be a full-time job that had not previously existed in the business, and
 must be filled by a resident of Iowa, and
 must be filled by the new employee for at least 12 months, and
 cannot be created as a result of a change in ownership of the business.
The credit is available for individual income, corporation income, franchise, insurance premiums and moneys
and credits tax.
If the annual wage and benefits for the qualified new job equals at least 130% of the annualized average
county wage but less than 160% of the annualized average county wage, the tax credit equals 5% of the
wages and benefits paid.
If the annual wage and benefits for the qualified new job equals at least 160% of the annualized average
county wage, the tax credit equals 10% of the wages and benefits paid.
More information on this credit is detailed in Iowa Administrative Rule 701-52.25. Information on the average
county wage is available at www.iowalifechanging.com/business/wagerates.html. Information on computing
the value of benefits is available at www.iowalifechanging.com/toolbox/downloads/empbenevalues.pdf.
If the business applying for the credit is a partnership, limited liability company, S corporation or estate or trust
electing to have the income taxed to an individual, the individual may claim the credit based on the pro rata
share of the individual’s earnings from the partnership, limited liability company, S corporation, or estate or
trust.
The total amount of wage-benefits tax credits issued in a fiscal year cannot exceed $10 million, and the credits
are issued on a “first-come, first-serve” basis. If a qualified job is entitled to the tax credit after the first 12
months of wages and benefits paid, the tax credit will be allowed for the next four subsequent tax years as long
as the job is retained. However, the business must still apply for the tax credit for these retained jobs for these
subsequent years.
If the application is approved, the Iowa Department of Revenue will send a tax credit certificate setting forth the
amount of the credit to the business.
This completed application is considered tax return information and is confidential in accordance with Iowa
Code sections 422.20 and 422.72.
MAIL APPLICATION TO:
IOWA DEPARTMENT OF REVENUE
EXAMINATION SECTION
P.O. BOX 10456
DES MOINES, IA 50306-0456
42-011a (9/24/07)