Application 8850

Pre-Screening Notice and Certification Request for the Work Opportunity Credit
8850

Job Applicant Information

-Read Privacy Act-

APPLICANT INFORMATION:

First Name*

Middle Name

Last Name*

Suffix

Social Security #*

Street Address (Physical Address)*

City or Town*

State*

ZIP code*

County*

If you are under age 40, enter your date of birth (month, day, year)

FORM 8850 QUESTIONS:

1		Check here if you received a conditional certification from the state workforce agency (SWA) or a participating local agency for the work opportunity credit.
2		Check here if any of the following statements apply to you. I am a member of a family that has received assistance from Temporary Assistance for Needy Families (TANF) for any 9 months during the past 18 months. I am a veteran and a member of a family that received Supplemental Nutrition Assistance Program (SNAP) benefits (food stamps) for at least a 3-month period during the past 15 months. I was referred here by a rehabilitation agency approved by the state, an employment network under the Ticket to Work program, or the Department of Veterans Affairs. I am at least age 18 but not age 40 or older and I am a member of a family that: Received SNAP benefits (food stamps) for the past 6 months; or Received SNAP benefits (food stamps) for at least 3 of the past 5 months, but is no longer eligible to receive them. During the past year, I was convicted of a felony or released from prison for a felony. I received supplemental security income (SSI) benefits for any month ending during the past 60 days. I am a veteran and I was unemployed for a period or periods totaling at least 4 weeks but less than 6 months during the past year.
3		Check here if you are a veteran and you were unemployed for a period or periods totaling at least 6 months during the past year.
4		Check here if you are a veteran entitled to compensation for a service-connected disability and you were discharged or released from active duty in the U.S. Armed Forces during the past year.
5		Check here if you are a veteran entitled to compensation for a service-connected disability and you were unemployed for a period or periods totaling at least 6 months during the past year.
6		Check here if you are a member of a family that: Received TANF payments for at least the past 18 months; or Received TANF payments for any 18 months beginning after August 5, 1997, and the earliest 18-month period beginning after August 5, 1997, ended during the past 2 years; or Stopped being eligible for TANF payments during the past 2 years because federal or state law limited the maximum time those payments could be made.
7		Check here if you are in a period of unemployment that is at least 27 consecutive weeks and for all or part of that period you received unemployment compensation.

Signature---All Applicants Must Sign

Under penalties of perjury, I declare that I gave the above information to the employer on or before the day I was offered a job, and it is, to the best of my knowledge, true, correct, and complete.

Job applicant's signature

* Select check-box in lieu of your signature

Date*

Under penalties of perjury, I declare that the applicant provided the information on this form on or before the day a job was offered to the applicant and that the information I have furnished is, to the best of my knowledge, true, correct, and complete. Based on the information the job applicant furnished on page 1, I believe the individual is a member of a targeted group. I hereby request a certification that the individual is a member of a targeted group.

Employer's Signature

* Select check-box in lieu of your signature

Name of Person Signing*

Title*

Date*

* As the employer, I understand that by submitting this application electronically, I am required by the IRS to keep a hard copy of the FORM 8850 for auditing purposes.

For Employer's Use Only

EMPLOYER INFORMATION:

Employer's Name*

Telephone no.*

EIN*

Street Address*

City or Town*

State*

ZIP code*

Employer's Email*

POINT OF CONTACT (If you are a POA Consultant, include company name) FIRST NAME / CONSULTANT NAME

First Name

Middle Name

Last Name

Suffix

Telephone no.

Street Address

City or Town

State

ZIP code

DATE APPLICANT:

Was Hired*

Started Job*