QUALIFICATION FORM

Company Name

First Name

Last Name

Phone# 555-555-5555

Estimate your potential employee retention credit amount

This is for estimate purposes only. The actual credit is based off of documents submitted. Potential ERC amount is based off the average count qualifying for all 6 quarters of the ERC program.

Average full-time W-2 employee count in 2020

Average full-time W-2 employee count in 2021

Potential ERC amount*

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