Tennessee Franchise Excise Job Tax Credit for Hiring Persons with Disabilities Business Plan

Franchise Excise Job Tax Credit for Hiring Persons with Disabilities Business Plan
Franchise and Excise Job Tax Credit for Hiring Persons with Disabilities Business Plan
RV-F1319501 (9/21)

TENNESSEE DEPARTMENT OF REVENUE
Franchise and Excise Tax
Job Tax Credit for Hiring Persons with Disabilities Business Plan
Taxpayer Name
Mailing Address

Street

Account Number

FEIN

City

State

ZIP Code

1. Newly Created Tennessee Jobs
Hiring Date

Employee Name

Last 4-digits
Social Security
Number

State Employment
Incentive Program

Full-Time Health Insurance
Provided
(Yes/No)
(Yes/No)

2. Tennessee Job Summary
Employment
Level

Fiscal
Year End

Workers With Disabilities at
Start of Fiscal Year

Workers With Disabilities at
End of Fiscal Year

Net Increase in
Qualified Jobs

Full-Time
Part-Time

The statements made on this business plan are true to the best of my knowledge and belief.

Taxpayer's Signature

Title

Date

Telephone

Instructions: Franchise and Excise Tax Job Tax Credit
for Hiring Persons with Disabilities Business Plan
General Information
A taxpayer must file this business plan in order to qualify for the job tax credit for hiring persons
with disabilities provided by Tenn. Code Ann. § 67-4-2109(f). The amount of the credit is $2,000 for
each qualifying part-time job and $5,000 for each qualifying full-time job when the employee is
enrolled in the taxpayer’s health insurance plan. The credit is subject to the limits indicated in Tenn.
Code Ann. § 67-4-2109(b)(1)(D). Any unused credit may be carried forward for up to 15 years. Note
that it is not necessary to make a required capital investment or be a qualified business enterprise
as defined in Tenn. Code Ann. § 67-4-2109(a) to claim a credit for hiring persons with disabilities.
The business plan must be filed and approved before any job tax credit can be taken on Schedule X
of the franchise and excise tax return. Each question on the business plan must be answered fully.
You must provide the complete legal name, mailing address, FEIN, and franchise and excise tax
account number of the taxpayer.
Newly Created Tennessee Jobs
Hiring Date: Indicate the date on which the employee was hired.
Employee Name: The name of the disabled employee hired by the taxpayer.
Social Security Number: Enter the employee's last four digits of their Social Security Number.
State Employment Incentive Program: This is the state-funded program through which the taxpayer
hired the disabled employee.
Full-Time: Indicate “Yes” if this is a full-time employee working at least 37.5 hours per week and
employed for at least 12 consecutive months. Indicate “No” if this is a part-time employee working at
least 10 hours per week and employed for at least 12 consecutive months. Please note that if the
employee is seasonal or works less than 10 hours per week, the taxpayer cannot claim a credit for
that employee and should not include the employee on this form.
Health Insurance Provided: Indicate “Yes” if the employee is enrolled in a health insurance program
through your company, and indicate “No” if the employee is not enrolled in a health insurance
program through your company. Health insurance must be provided in order to claim the $5,000
credit for full-time employees. If health insurance is not provided, the $2,000 credit applies to fulltime and part-time employees alike.
Tennessee Job Summary
Fiscal Year End: The last day of the fiscal year in which the jobs were created (mm/dd/yyyy).
Workers with Disabilities at Start of Fiscal Year: Indicate the number of full-time and/or part-time
workers with disabilities employed by the taxpayer at the start of the fiscal year.
Workers with Disabilities at End of Fiscal Year: Indicate the number of full-time and/or part-time
workers with disabilities employed by the taxpayer at the end of the fiscal year.

Net Increase in Qualified Jobs: Indicate the net increase in qualified jobs. This is the number of new
jobs that should be claimed on Schedule X of the franchise and excise tax return.

Mail the completed business plan to:
Tennessee Department of Revenue
P.O. Box 190644
Nashville, TN 37219-0644
For tax assistance call (800) 397-8395 in Tennessee, or if you are located in the Nashville call area or
out-of-state, call (615) 253-0700.