Minnesota Certification of Job Opportunity Building Zone (JOBZ) Compliance with Business Subsidy Agreement (BSA)

Certification of Job Opportunity Building Zone (JOBZ) Compliance with Business Subsidy Agreement (BSA)
2012 JOBZ1
JOBZ Certification (JOBZ1)

Certification of Job Opportunity Building Zone (JOBZ)
Compliance with Business Subsidy Agreement (BSA)
Qualified businesses: you must complete and file by October 15, 2017
Name of qualified business			

Taxpayer name (if different from JOBZ business) 	

JOBZ ID number

Business address in the zone						

FEIN

City	

Minnesota tax ID number

State	

County	

MN

	
Taxpayer: 	

Zip code	

C-Corporation	

S-Corporation	

Business contact’s name (first, last)	

Partnership	

Individual	

Title		

Fiduciary	

Other (Specify):	

Daytime phone

Email address of qualified business (optional)	

Primary parcel ID (if more than one, attach a sheet)

	

Date of Business subsidy agreement

	1	 Are you operating in the zone? (If “no,” stop here; sign and submit this form.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1	

	 Yes	

No	

	2	 Was there a relocation agreement that required you to create a specific number of jobs? (If “no,” skip line 3)  . . . . . . . . . . 2	

	 Yes 	

No

	3	 Are you meeting that requirement? (If “no,” attach an explanation.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3	

	 Yes 	

No

	 Yes 	

	No	

	4	 Number of jobs promised in the business subsidy agreement (BSA) . . . . . . . . . . . . . . . . . . . . . . . . 4	
	5	 Number of employees in the JOBZ zone at the time you filed this form . . . . . . . . . . . . . . . . . . . . . 5	
	6	 Minimum wage requirement in the BSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6	
	 	 Is the above business in compliance with lines 4 and 6 and all other requirements of the BSA? . . . . . . . . . . . . . . . . . . . . . 7	
7
		 (If “no,” attach an explanation)
Businesses that fail to submit this form or businesses that materially misrepresent their compliance with the JOBZ BSA are:
1) permanently disqualified from receiving future JOBZ benefits; and 2) subject to repayment of prior benefits received.
I declare that this report is correct and complete to the best of my knowledge and belief.
Signature of authorized representative of qualified business	

Date	

This certification is required to be filed annually by October 15, as a condition of continuing eligibility for JOBZ benefits.
Mail to: 	
	
	
	
	

Minnesota Revenue
Mail Station 6330
St. Paul, MN 55146-6330
Phone: 651-556-6836
Fax: 651-556-3102

9995

JOBZ Certification (JOBZ1) Instructions
Who must complete this form?

If you are a qualified business participating in the Job Opportunity Building Zone
(JOBZ) program, you must provide a fully
completed certification of eligibility each
year with the Department of Revenue. This
form is used to determine continued eligibility to receive JOBZ benefits and must be
received no later than October 15.
Failure to submit the JOBZ Certification
will result in removal from the JOBZ program. You will also be subject to repayment
of prior JOBZ tax benefits received.
This form is in addition to any other reporting requirements with the Department of
Revenue, the zone administrator, or the
Department of Employment and Economic
Development (DEED).
In addition, businesses that have been
terminated from the JOBZ program but
maintain a substantial level of the activities
described in the business subsidy agreement
should continue to file this form for the
duration of the zone term. Completing this
form will assist the Department of Revenue
in verifying the business’s continued operations within the zone.

Qualified business

You are a qualified business if your place of
business is located within a JOBZ zone and
you have signed a Business Subsidy Agreement with the zone administrator.
A qualified business also includes an
agricultural processing facility located in a
designated agricultural processing facility
zone.

Eligibility requirements

As a qualified business, you are required to
meet and maintain your eligibility requirements as determined by your business
subsidy agreement (BSA).

Email address

Please note that:

If the department has questions regarding your Form JOBZ Certification form
and you want to receive correspondence
electronically, be sure to provide your email
address.

1.	 Businesses that properly indicate
“NO” on lines 1 or 3 are no longer
eligible for JOBZ benefits, and are subject to the JOBZ repayment provisions
of Minnesota Statute § 469.319.

Enter on line 5 the number of employees
currently in the JOBZ zone. Do not use the
number of employees you had when you
entered the JOBZ program.

2.	 Other businesses that properly indicate “YES” on line 1, but “NO” on line
7 may not be subject to repayment of
JOBZ benefits, and under certain circumstances may be eligible for limited
future JOBZ benefits.

County and parcel ID number

Enter the county in which the qualified
business is located. Enter the main property’s parcel ID, or property ID, number
assigned to it by the county. You can find
the parcel or property ID number on the
property tax statement.

Minnesota business ID number

Enter the registered Minnesota business ID
number. This is a seven digit number and is
used to file your Minnesota tax filings.

JOBZ ID number

Enter your Minnesota JOBZ ID Number
which can be located on your JOBZ M500
form.

Business Subsidy Agreement (BSA)
date

In the area provided, enter the date the qualified business’s Business Subsidy Agreement (BSA) was signed.

Line 5

Signature

An authorized representative of the qualified business must sign and date the form.

When to file

By October 15, 2017, mail JOBZ Certification form, to:
Minnesota Revenue
Mail Station 6330
St. Paul, MN 55146-6330
or fax to: 651-556-3102
Do not submit this form with your tax
return.

Use of information

All information provided on JOBZ Certification form is public.
The information will be used to administer
the JOBZ program, and will be shared with
the Department of Employment and Economic Development to the extent necessary
to administer the JOBZ laws.

Questions or need forms?

You can find forms and the most current
information on our website at
www.revenue.state.mn.us.
If you have questions, call 651-556-6836
during business hours.
We’ll provide information in other formats
upon request.