2020 Retroactive Employee Retention Tax Credit (ERTC) Request Form

2020 Retroactive Employee Retention Tax Credit (ERTC) Request Form

Revised 3/9/22
Company Number*
Company Name*
Client Number
Client Name
Contact Name*
Date*

MonthDayYear
Date
The COVID-19 stimulus package allows for a refundable credit up to $5,000.00 per employee based on a 50% tax credit of qualified wages up to $10,000 for 2020 (3/12/20-12/31/20).

PayData can facilitate reporting of the retroactive 2020 Employee Retention Tax Credit (ERTC) by filing an amended Quarterly Tax Return, Form 941-X.

ALERT: Consideration must be made prior to completing this form. Employers must review eligibility with their CPA or Tax Accountant to ensure that your company is eligible for the ERTC or have plans to apply for other programs in 2021. PayData is not responsible for determining ERTC eligibility.

Please refer to this website for eligibility guidelines:

https://www.irs.gov/newsroom/new-law-extends-covid-tax-credit-for-employers-who-keep-workers-on-payroll

PayData ERTC Service fees do apply in calculating the value of the ERTC credits. Client understands and agrees to PayData ERTC service fee of 5% of the client’s approved ERTC credit amount, with a cap of $1,000 per quarter. The service fees will be debited within the next 30 days or the company's next payroll, whichever comes first.

To begin applying the 2020 ERTC credit, please complete this 2020 ERTC Credit Request form.
Please enter the date range your company was eligible for the ERTC.
ERTC Begin Date*

MonthDayYear
Date
ERTC End Date*

MonthDayYear
Date
(Note: PayData ERTC service is based on current legislation and is subject to change.)
Did you use Payroll Protection Program (PPP) funds in payroll during the period you were eligible for ERTC?*
Please Note: If you have received and applied any PPP funding for payrolls processed within this date range, please indicate the payroll check dates that these funds were applied. These dates will be excluded from ERTC calculations.
PPP payroll check dates - Begin Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Please indicate below all employees that should be excluded from ERTC calculations.
Please note: relatives to the employer or individuals owning over 50% should not be included.

Determining Qualified Wages for COVID-19 Related Employee Retention Credits
Exclude the following employees from ERTC calculations:
Please check this box if you would like to include Qualified Health Plan Expenses in your retention credit calculation.
IRS Defines Qualified Health Plan Expenses
Authorized Client Representative*
Title*
Signature*
Date

MonthDayYear
Date
Should be Empty: