Louisiana Louisiana Youth Jobs Tax Credit Employer Application

Louisiana Youth Jobs Tax Credit Employer Application
Form R-90004
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

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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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

R-90004-B (1/24)	

Louisiana Youth Jobs
Tax Credit Employee Certification

Attach completed form to Form
R-90004, Louisiana Youth Jobs
Tax Credit Application.

Louisiana Revised Statute 47:6028

Louisiana employers hiring youth ages 16 to 23 that meet certain criteria may be eligible to earn Louisiana Youth Jobs Tax Credits.
Complete this certification for your employer to determine if your hiring may qualify for the tax credit program.
Employee Information (To be completed by the employee.)
Employer’s Name

Employee’s Name

Social Security Number

Address

City

Date of Birth (mm/dd/yyyy)

State

Age

ZIP

Date Hired (mm/dd/yyyy)

Complete Sections 1 and 2 below to help your employer determine if they are eligible to earn a tax credit for your
employment. At least one box in each section must be checked.
Section 1: Verification of age and employment at date of hire (check all that apply):
■ 	 I was at least 16 years old but under 24 years old at the date of hire. You must attach a copy of a state issued
license or ID that contains your date of birth.
■	 I was unemployed prior to being hired by the business listed above.
■	 I did not meet any of the criteria listed in Section 1 at date of hire.
Section 2: Verification of eligible criteria at the date of hire (check all that apply):
■	 I was at least 18 years old, no longer in school, and do not have a high school diploma, HiSET or GED credential,
or high school equivalency diploma.
■	 I was a member of a family that is receiving assistance from the Family Independence Temporary Assistance
Program.
■	 I was a member of a family that is receiving benefits through the Supplemental Nutrition Assistance Program.
■	 I was a member of a family that is receiving assistance from the Kinship Care Subsidy Program.
■	 I was a member of a family that is receiving assistance or benefits under the Temporary Assistance for Needy
Families Program.
■ 	 I have served time in jail or prison, or I am currently on probation or parole.
■	 I was pregnant or a parent.
■	 I was homeless.
■	 I was in or currently in foster care, extended foster care, or the custody of the Department of Children and Family
Services.
■	 I was a veteran. You must attach a copy of your DD214 – Certificate of Release or Discharge from Active Duty.
■	 I was the child of a parent who is currently incarcerated or was released from incarceration within the past two years.
■	 I live in public housing or receive housing assistance, such as a Section 8 voucher.
■	 I did not meet any of the criteria listed in Section 2 at date of hire.

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 employer to legal and tax consequences, including but not limited to recapture of any credits
granted on the basis of such misrepresentation.
Signature

Date (mm/dd/yyyy)