Form   8974:           Qualified Small Business Payroll Tax Credit for Increasing Research                                       Activities 950817
                                                                                                                                        OMB No. 1545-0029
(Rev. December 2017)   Department of the Treasury — Internal Revenue Service
                                                 —                                                                 Report for this quarter . . . 
Employer identification number (EIN)
                                                                                                                 Check only one box.
Name (not your trade name)                                                                                           1: January, February, March
                                                                                                                     2: April, May, June
The credit from Part 2, line 12, will be       Form 941, 941-PR, or 941-SS                                           3: July, August, September
reported on (check only one box):
                                               Form 943 or 943-PR                                                    4: October, November, December

                                               Form 944 or 944(SP)

Calendar year                              You must select a quarter if you file Form 941, 941-PR, or 941-SS.

Part 1: Tell us about your income tax return.
           (a)                        (b)            (c)                       (d)          (e)                        (f)                  (g) 
        Ending date                 Income         Date income                 EIN        Amount from              Amount of credit     Remaining credit 
        of income                   tax return     tax return               used on     Form 6765, line 44,        from column (e)     (subtract column (f) 
        tax period                  filed that       was filed              Form 6765   or if applicable,            taken on a         from column (e))  
                                    included                                            the amount that          previous period(s)  
                                 Form 6765                                              was allocated 
                                                                                          to your EIN  

1       /            /                             /     /                                          .                      .                    .
2       /            /                             /     /                                          .                      .                    .
3       /            /                             /     /                                          .                      .                    .
4       /            /                             /     /                                          .                      .                    .
5       /            /                             /     /                                          .                      .                    .
6      Add lines 1(g) through 5(g) and enter the total here       . .       .  .   .  . . . . .              . . . . . .   .     .   .          .
Part 2: Determine the credit that you can use this period.

7      Enter the amount from Part 1, line 6(g) .     . .   .   .  . .       .  .   .  . . . . .              . . . 7                            .

8      Enter the amount from Form 941 (941-PR or 941-SS), 
       line 5a, Column 2; Form 943 (943-PR), line 3; or Form 
       944 (944(SP)), line 4a, Column 2          . . . .   .   .  .         8                                  .

9      Enter the amount from Form 941 (941-PR or 941-SS), 
       line  5b,  Column  2;  or  Form  944  (944(SP)),  line  4b, 
       Column 2 .      . .     .    . .   .    . . . . .   .   .  .         9                                  .

10     Add lines 8 and 9       .    . .   .    . . . . .   .   .  .         10                                 .

11     Multiply line 10 by 50% (0.50). Check this box          if you're a third-party payer of sick pay or
       check this box          if you received a Section 3121(q) Notice and Demand. See the
       instructions before completing line 11 .      . .   .   .  . .       .  .   .  . . . . .              . . . 11                           .

12  Credit. Enter the smaller of line 7 or line 11. Also enter this amount on Form 941 (941-PR 
       or 941-SS), line 11; Form 943 (943-PR), line 12; or Form 944 (944(SP)), line 8 .       .              . . . 12                           .
For Paperwork Reduction Act Notice, see the separate instructions.             www.irs.gov/Form8974              Cat. No. 37797C   Form 8974 (Rev. 12-2017)