Schedule IT-40QEC State Form 21928 (R5 / 9-10) Indiana Department of Revenue Enterprise Zone Qualified Employee Deduction Certificate Enclosure Sequence No. 18 2010 --- File with your Indiana individual income tax return --Name of employee Social Security Number Name of Enterprise Zone ___________ Date of residence in Enterprise Zone: From ____________ To ____________ Employee’s street address Amount of compensation for tax year during the period of residence in the Enterprise Zone: $_________________ City of residence Caution: Limitation of Deduction Enter ½ of the above amount or $7,500, whichever is less: $________________ Employer Address Federal Identification Number I certify that the above-named employee was paid the amount indicated as compensation for services rendered, and that he/she is a qualified employee as defined in I.C. 6-3-2-8. Signature of employer Title Telephone number Date Instructions for completing Schedule IT-40QEC Schedule IT-40QEC is to be completed by the enterprise zone employer and distributed to its qualified employee(s). The qualified employee should claim this deduction on IT-40 Schedule 2, IT-40PNR Schedule C, or Form IT-40X (amended tax return). The employee must enclose the IT-40QEC with the state individual income tax return to support any claimed deduction of earned enterprise zone income. Indiana Code I.C. 6-3-2-8 defines a “qualified employee” as an individual who: 1. Has a principal place of residency in the enterprise zone where employed; 2. Performs services for the employer 90 percent of which are directly related to the conduct of the employer’s trade or business located in an enterprise zone; 3. Performs services for the employer at least 50 percent of the time during the taxable year within an Indiana state enterprise zone; and 4. Is employed by a business that remains eligible to receive benefits and incentives as provided by enterprise zone legislation. Portions of certain Indiana cities are designated as state enterprise zones. Also, certain airport development zones may substitute as enterprise zones. A qualified employee living and working in a designated enterprise zone may be entitled to deduct from state adjusted gross income one-half of the enterprise zone income earned for services or $7,500, whichever is less. Enterprise zone income means wages, salaries, commissions and any other forms of remuneration paid to qualified employees for services by an enterprise zone employer, minus any IRA deductions directly related to that earned income. For a listing of all current enterprise zones and contact information for each zone please visit www.in.gov/dor/3619.htm Privacy Notice: The records in this series are CONFIDENTIAL according to the provisions of I.C. 6-8.1-7-1 and I.C. 5-28-15-8 *21310111694* 21310111694 American LegalNet, Inc. www.FormsWorkFlow.com