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2022
VIRGINIA ENTERPRISE ZONE PROGRAM
Job Creation Grant Qualification Form
Print on 8 1/2" x 11" paper for your own records.
Read the 2022 Job Creation Grant Instruction Manual before completing this form.
Form EZ-JCG
PART I: BACKGROUND INFORMATION
1. Business Firm Legal Name
 2. Trading name, if different than Legal Name
 3. Date Bus. Began Operation in Zone
(MM/DD/YYYY)
4. Federal Employment ID# (FEIN)
5. Activity # (First three digits of the NAICS. See Instruction Manual)
6. Physical Address of Zone Establishment
City/County/Town
   Zipcode
7. Type of Application
8. Type of Job Creation Made by the Applicant



 Note: Firms are not eligible to apply for the JCG if simultaneously closing a facility in Virginia.
9. If applicable, Federal Employment ID# (FEIN) of Parent Company
 10. If the Firm is Subsidiary, Name of the Parent Company
11. Zone Name
   12. Zone #
   13. Zone Designation Date
   14. Name of Local Zone Administrator
15. Must upload Local Zone Administrator Review in Part VI. Check to confirm the LZA Review document is signed and uploaded.
 
PART II: QUALIFICATION INFORMATION
In order to calculate the number of grant eligible employees and determine the applicable grant amount, please complete the JCG Worksheet prior to completing this section. Values from the JCG Worksheet are used to complete #4 and #5 below (indicated in italics below).
1. 
Grant is requested for calendar year (YYYY).2. Check year of qualification.
3.  Base Calendar year used by the business firm (YYYY).   This base year remains the same for the five years of qualification.
4.  New Job Creation  (Note: PFTP=Permanent full-time position.)
  All documented jobs must exclude positions in retail, food and beverage, and personal service.
  A.  # of all equivalent PFTP filled by the firm during the BASE year. (Sheet 2 of JCG Worksheet, Cell B3) A 
  B.  # of all equivalent PFTP filled by the firm during the GRANT year. (Sheet 2 of JCG Worksheet, Cell B4) B 
  C.  Increase in the # of equivalent PFTP created over the base year. Subtract line (A) from line (B). C 
  D.  New jobs created over four net new job threshold. Subtract 4 from line (C).
Note: If line (C) is equal to or less than 4, the firm will not qualify for job creation grants.		 D 
5.  Grant Eligible Employees
  E.  New eligible PFTP filled in grant year earning at least 175% of the minimum wage and offered health care benefits.
* List total new grant year equivalent PFTP indicated on JCG worksheet (B5) meeting this requirement.		 E 
  F.  Net new eligible PFTP filled in grant year earning at least 150% of the minimum wage (but less than 175%) and offered health care benefits.
* List total new grant year equivalent PFTP indicated on JCG worksheet (B6) meeting this requirement.		 F 
  G.  Number of new grant year PFTP meeting wage and health benefits requirements.
* Add lines (E) and (F)		 G 
Calculation of Grants
Firms cannot receive grants for more than the net new PFTP over the four job threshold (Part II, 4D).
 * If line D is greater than line G, use numbers on lines E and F to calculate the grant amounts on line 6A and 6B.
When line G is greater than line D...
* If line E=0, then:
 . Multiply line D by $500 and enter total on line 6B and "0" on line 6A.
* If line F=0, then:
 . Multiply line D by $800 and enter total on line 6A and "0" on line 6B.
* If values on both line E and F, then:
 . Presuming line E is less than line D, multiply line E by $800 and enter total on line 6A.
 . Subtract line E from line D and multiply amount by $500. Enter total on line 6B.
 . If line E is greater than line D, multiply line D by $800 and enter total on line 6A, and "0" on line 6B.
6.  Grant Requests
  A.  Requested JCG award for PFTP earning at least 175% of minimum wage and offered health care benefits.
* Using above procedures, multiply appropriate number by $800.		 $ 
  B.  Requested JCG award for PFTP earning at least 150% of minimum wage(but less than 175% of the minimum wage) and offered health care benefits.
* Using above procedures, multiply appropriate number by $500.		 $ 
  C.  Total amount of job creation grants requested.
* Add lines (A) and (B).		 $ 
7. 
I used DHCD's JCG Worksheet template to complete this application.
8. 
I have reviewed the CPA Attestation Report and corrected any deficiencies noted by the report.
9.  I have NOT used an average wage or final wage to represent the annual wage rate of an employee.  
 
PART III: CONTACT INFORMATION
1. Name of Grant Applicant Representative
First: Last:		 Title
 Daytime Phone #
 E-mail Address
Principal Mailing Address(grant correspondence is mailed to)
 City
 State
 Zip Code
2. Certified Public Accountant (preparer of required Attestation Report)
Name of Certified Public Accountant
 VA License #
 Daytime Phone #
 E-mail Address
3. Accounting Firm
 Address
City
State
    Zip Code
 
PART IV: DECLARATION
 
KEEP A COPY OF THIS FORM FOR YOUR RECORDS. The Department may at any time review qualified zone businesses records related to qualification under this section to assure that information provided in the application process is accurate. Qualified zone businesses shall maintain all documentation regarding qualification for Enterprise Zone Job Creation Grants for at least one year after the final year of their five-year grant period. Job Creation Grants that do not have adequate documentation regarding permanent full-time positions, "report to work" requirements, wage rates and provision of health benefits may be subject to repayment by the qualified zone business.
The application form and final CPA attestation report are due by April 1st of the calendar year subsequent to the grant year (Part II, Item 1). Applications submitted by April 1st without the required attestation report shall be considered late applications. If the April 1 deadline falls on a weekend or holiday, applications are due the next business day.
All documents MUST be submitted electronically through the EZ Submission System/Portal. Hard copies are NOT accepted.
Any applications submitted without the required CPA attestation report or submitted after the due date but before May 15th of the calendar year subsequent to the qualification year will be held until the Department determines that funds remain without the need to prorate on-time grant awards. At such time, the Department will review and process such applications on a first-come, first served basis.
 
PART V: COMMENTS
Please enter your notes here:
 
PART VI: UPLOAD DOCUMENTS
* Password protected documents will NOT be accepted. All documents must be uploaded separately (one PDF with all of the documents will NOT be accepted).
Form EZ-JCG or Form EZ-JCG-HUA*  
JCG Worksheet Sheets - Excel version*  
CPA Attestation Report Form  (If Not Exempt)
COV Form W-9*  
LZA Review*  
Additional Information  
Additional Information  
Additional Information  
Additional Information  
Additional Information  
Check COV W-9 Remittance Address to be sure that this is the correct address to which the Department will send the company's grant check.  
 
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