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Slide 1: R-1040 (9/07) Quality Jobs Income Tax Rebate Claim Mail to: Office Audit Division ICFT Unit P. O. Box 66362 Baton Rouge, LA 70896-6362 (225) 219-2270 Please print or type. Date of Claim (mm/dd/yyyy) LA Revenue Account Number Quality Jobs Contract No. Legal Name of Business Trade Name of Business Mailing Address Project Location Address City State ZIP City State ZIP Effective Date of Contract or Renewal (mm/dd/yyyy) Date Affidavit of Annual Certification was certified (mm/dd/yyyy) Rebate for Tax Year Ending ................................................................................................... Payroll ...................................................................................................................................... Benefit Rate ............................................................................................................................. Rebate Earned ........................................................................................................................ % DECLARATION I declare that to the best of my knowledge of all available information, this rebate claim is true and complete and complies with all statutes, rules and regulations, and any other policy pronouncements related to the Quality Jobs program. Signature of Officer, Owner or Other (for Other, attach Power of Attorney): Date (mm/dd/yyyy) Name Title