Empire State Apprenticeship Tax Credit - Employer Final Report

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ESATC Employer Final Report

Empire State Apprenticeship Tax Credit - Employer Final Report

Governor Kathy Hochul

* Indicates required fields

If you have any questions you can contact us at (877) 226-5724 or E-mail

An Employer Final Report form must be submitted for each apprentice you are claiming after they have worked full time for at least six months (35 hours per week).

For the purposes of this form, a Sponsor is an employer who operates their own New York State Registered Apprenticeship Program; a Signatory Employer is an employer who participates in a New York State Registered Apprenticeship Program run by another entity such as an association or Joint Apprenticeship Committee.

I am a: *

Name of NYS Registered Apprenticeship Sponsor*

Sponsor Code*

The Sponsor Code may be found on the Sponsor's Apprenticeship Training Program Registration Agreement (Form AT-10)

Name of NYS Registered Apprenticeship Trade*

ATP Code*

The ATP (trade) Code may be found on the Sponsor's Apprenticeship Training Program Registration Agreement (Form AT-10)

Name of Employer applying for this tax credit*

Apprentice Information

To be eligible for the tax credit, the apprentice's start date must be on or after 1/1/18 and they must have worked full time (35 hours per week) for at least 6 months.

First name:*

Last name:*

Date of Birth (MM/DD/YYYY)*

Apprentice Year in Apprenticeship Program is determined on the last day (December 31st) of the current year or the apprentice’s last day in the program (if the apprentice is no longer enrolled)

Apprentice Year in Apprenticeship Program: *

Worksite Location *

Address Line 1

Address Line 2

City *

State *

Zip *

Check the box if the apprentice had and/or will have a mentor for the full calendar year I confirm the apprentice had and/or will have a mentor for the full calendar year

A mentor is someone who provides instruction, counseling, guidance, and support to the apprentice on a regular basis throughout the calendar year. (Please note the mentor may be performing the same functions as the supervisor/journey worker but is also aiding the apprentice with other wraparound support services to ensure the apprentice completes the program and keeps his or her employment.)

Check the box if the apprentice is a Disadvantaged Youth I confirm that the apprentice is between the ages of 16 and 24 (at the time of enrollment into the apprenticeship) and currently meets one or more of the following categories:

Over 18 and no longer in school, without a high school diploma or a high school equivalency diploma.
Veteran
Member of a family that receives:
- Aid from Temporary Assistance for Needy Families.
- SNAP benefits (food stamps).
- Supplemental Security Income benefits.
- Free or reduced-cost school lunch.
Referred by a rehabilitation agency approved by the state, or an employment network under the Ticket to Work Program.
Served in jail or prison
On probation or parole.
Pregnant or a parent.
Homeless.
Is now or has been in foster care or the custody of the New York State Office of Children and Family Services.
The child of a parent who is:
- In jail/prison, or has been in the past two years
- Collecting unemployment insurance
Lives in public housing or receives housing assistance such as a Section 8 voucher.
Other risk factor not identified above

First Name of person submitting form*

Last Name of person submitting form*

Phone Number*

( ) - ext.

E-mail*

Confirm E-mail*

Terms of Service Agreement

I acknowledge the following:

The apprentice listed above has been employed in a full-time position of at least 35 hours per week for at least 6 months in the calendar year for which the tax credit is being claimed.

The apprentice listed above started their apprenticeship on or after January 1, 2018.

The apprentice listed above has not been in the apprenticeship program beyond one year of their expected completion date (e.g. length of program plus one year).

The apprentice listed above has been registered with the New York State Department of Labor with an Apprenticeship Agreement form (AT-401 Form).

The Empire State Apprenticeship Tax Credit cannot be combined with any other New York State tax credit for the apprentice.

To the best of my knowledge, this information is true, correct and complete. I am aware that there are significant civil and criminal penalties for filing false documents or other information with the government.

By checking this box and submitting this form, I agree to the above Terms of Service Agreement.