JobCT Tax Rebate Program Application

JobsCT Tax Rebate Program Application
Application Instructions
General Description

This request for Business Assistance is a brief outline to enable the DECD to determine, on a preliminary basis, the suitability and eligibility of the business to apply for the JobsCT Tax Rebate Program. A current business plan should be included (consult with your project manager if assistance is needed). The business plan should support the projected job growth.

All information accompanying this application is confidential and exempt from the Freedom of Information Act.

Instructions: Click to show more
1. Business Name: List the full legal name of the applicant for financial assistance.
2. Address: Mailing address where correspondence should be sent. If different from the applicant location, indicate.
3. Contact Person: If appropriate, include title.
4. Project Location: Project location.
5. Opportunity Zone: Identify if this project is in an Opportunity Zone.
6. Distressed Municipality: Identify if this project is in a Distressed Municipality.
7. Type of Business: Indicate type of Product or Service (e.g. manufacturing, technology, machining, etc.). Including the NAICS Code, Federal Employer ID # or Social Security # and State Tax Registration #.
8. Connecticut Employment as of the date of this application: Provide Current Connecticut
employment information broken out by the identified demographic.
9. Full Time Equivalents & Average Annual FTE Wages: Identify current Full Time Equivalents and average annual FTE wage. Identify Average Annual FTE wages projections for the length of your project.
(1 Full Time Equivalent (FTE) is a minimum of 35 worked hours per week.)
10. Disadvantaged Community Job Creation: Identify if this project will create jobs for any of the targeted disadvantaged communities listed.
11. Anticipated Capital Expenditures: Provide the amount budgeted by the company to execute this project, broken out by category.
12. Gross Sales/Receipt: Provide the total amount of income from all operations during the last fiscal accounting year. 13. Form of Ownership: Indicate the company’s structure.
14. Business Ownership: If not practical to list every business owner, include owners holding 10% or more of the business. If ownership of the borrower is different from the business, please list on a separate sheet the owners of the borrower. Minority or woman ownership must be 51% to be considered for this status. (“Minority” includes a variety of categories such as racial, ethnic, gender and disability status).
15. Unpaid Taxes: Provide unpaid tax information by fiscal authority.
16. Pending or Anticipated Claims or Litigations: Check appropriate box and provide information, if applicable.
17. Bankruptcy Information: Check appropriate box and provide information, if applicable.
18. Have you received prior state funding: Identify funding source, program, amount and funding date, if applicable.
19. Environmental Compliance: Check appropriate box and provide information, if applicable.
20. OSHA Compliance: Check appropriate box and provide information, if applicable.
21. Public Disclosure: Check appropriate box and provide information, if applicable.
22. Required Documents: Please attach the following documents.

JobsCT Tax Rebate Program Application
1. Business Legal Name:*
2. Address:*
City:*
State:*
Zip Code:*
3. Contact Person and/or Title:*
Phone: *
Email:*

Confirmation EmailEmail confirmation
Company Website:
4. Project Location

If address is same as #2, click here
Address:*
City:*
State:*
Zip Code:*
5. Is this project located in an Opportunity Zone? (Link to map)*

YesNo
6. Is this project located in a Distressed Municipality? (Link to map)*

YesNo
7. Type of Business:*
If you selected "Other", please specify:
Type of Product or Service:*
NAICS Code ( Link to NAICS ):*
Federal Employer Identification Number (EIN) or Social Security Number:*
State Tax Registration Number:
Department of Labor Unemployment Insurance Number (UI #):

8. Current CT Employment as of the date of this application:

Current Connecticut Employment:*

	Number of Jobs	Minority	Disabled	Veteran
Current Employees:

9. Current Connecticut FTE's & Average Annual Connecticut W-2 Compensation (1 Full Time Equivalent (FTE) is a minimum of 35 worked hours per week.)
Current Connecticut FTE's:*
Average Annual Connecticut W-2 Compensation for Current FTE's (For purposes of clarity, please enter your answers with appropriate comma separations, i.e.: $100,000 instead of $100000):*
NEW EMPLOYMENT: Please show year-by-year how employment will “ramp up” (if any), using the incremental number of new jobs created each year, as the cumulative total will be calculated automatically. For example, if the firm creates 50 new jobs in 2024 and the firm adds 15 new jobs in 2025, put 50 in 2024 and 15 in 2025.

Projected FTEs:*

	2024	2025	2026	2027	2028	2029	2030
Full time jobs created and maintained for the calendar year
Cumulative jobs created
Average Annual Connecticut W-2 Compensation

*Salaries must be 85% of the median household income of the municipality where the jobs will be located.
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10. Will this project create jobs for any of the following individuals: (a) receiving or have received services from the Department of Aging and Disability Services; (b) are receiving employment services from the Department of Mental Health and Addiction Services or participating in employment opportunities and day services, as defined in section 17a-132 226 of the general statutes, operated or funded by the Department of Developmental Services; (c) have been unemployed for at least six of the preceding twelve months; (d) have been convicted of a misdemeanor or felony; (e) are veterans, as defined in section 27-103 of 136 the general statutes; (f) have not earned any postsecondary credential and are not currently enrolled in a postsecondary institution or program; or (g) are currently enrolled in a workforce training program fully or substantially paid for by the employer that results in such individual earning a postsecondary credential.*

YesNo

	Dollar Amount
Construction/Leasehold Improvements
Furniture and Fixtures
Machinery and Equipment
Computer Software
Computer Equipment
Other
Total

	Amount	Past Due	Payment Terms
Federal
State
Local

	Amount received $	Program	Date
Amount
Amount
Amount
Amount

	Name	Title	% of Ownership
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2
3
4

JobsCT Tax Rebate Program Application

Application Instructions

JobsCT Tax Rebate Program Application