This form contains 13 fields organized into 4 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name Type Description
Calculations
2 Add lines 1a, 1b, and 1c. See instructions for the adjustment you must make to your deduction for salaries and wages 2 Text
Add the amounts from lines 1a, 1b, and 1c. Refer to the instructions for any adjustments you must make to your deduction for salaries and wages.
Qualified Wages
b Qualified first-year wages of employees who worked for you at least 400 hours Text
Enter the total qualified first-year wages of employees who worked for you at least 400 hours.
C Qualified second-year wages of employees certified as long-term family assistance recipients Text
Enter the total qualified second-year wages of employees certified as long-term family assistance recipients.
Taxpayer Information
Name(s) shown on return Text
Enter the name(s) as shown on your tax return.
Identifying number Text
Enter your identifying number, such as your Social Security Number (SSN) or Employer Identification Number (EIN).
Max length: 11 characters
Unlabeled Fields
Text
This field is not labeled. Please refer to the form instructions or context to determine the appropriate information to enter.
topmostSubform[0].Page1[0].f1_4[0 Text
This field is not labeled. Please refer to the form instructions or context to determine the appropriate information to enter.
topmostSubform[0].Page1[0].f1_6[0 Text
This field is not labeled. Please refer to the form instructions or context to determine the appropriate information to enter.
topmostSubform[0].Page1[0].f1_8[0 Text
This field is not labeled. Please refer to the form instructions or context to determine the appropriate information to enter.
3 Text
This field is not labeled. Please refer to the form instructions or context to determine the appropriate information to enter.
4 Text
This field is not labeled. Please refer to the form instructions or context to determine the appropriate information to enter.
5 Text
This field is not labeled. Please refer to the form instructions or context to determine the appropriate information to enter.
6 6 Text
This field is not labeled. Please refer to the form instructions or context to determine the appropriate information to enter.