Form 8850 Pre-Screening Notice and Certification Request for the W

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Date

Form

8850

(Rev. March 2009)

I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 8850, PAGE 1 of 2
MARGINS: TOP 13mm (1⁄ 2 "), CENTER SIDES. PRINTS: HEAD to HEAD
PAPER: WHITE, WRITING, SUB. 20
INK: BLACK
FLAT SIZE: 219mm (81⁄ 2 ") 3 279mm (11")
PERFORATE: (NONE)
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Action

Date

O.K. to print
Revised proofs
requested

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

Department of the Treasury
Internal Revenue Service

Signature

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OMB No. 1545-1500

See separate instructions.

Job applicant: Fill in the lines below and check any boxes that apply. Complete only this side.
Your name

Social security number

Street address where you live
City or town, state, and ZIP code
County

Telephone number

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

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1

Check here if you are completing this form before August 28, 2009, and you lived in the area impacted by Hurricane
Katrina on August 28, 2005. If so, please enter the address, including county or parish and state where you lived at that
time.

2

Check here if you received a conditional certification from the state workforce agency (SWA) or a participating local agency
for the work opportunity credit.

3

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:
a Received SNAP benefits (food stamps) for the past 6 months, or
b 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 discharged or released from active duty in the U.S. Armed Forces during the past 5 years
and, for at least 4 weeks during the past year, I received unemployment compensation.
● I am at least age 16 but not age 25 or older and during the past 6 months (a) I have not regularly attended (less than
half any required days or hours) any high school, technical school, or college, (b) if employed, I earned less than a
minimum wage employee working 30 hours a week for the entire 6-months, and (c) I have not completed more than
one semester or quarter (or the equivalent) at a technical school or college.
Check here if you are a veteran entitled to compensation for a service-connected disability and, during the past year,
you were:

delete
hyphen
4

● Discharged or released from active duty in the U.S. Armed Forces, or
● Unemployed for a period or periods totaling at least 6 months.
5

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.
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

©

For Privacy Act and Paperwork Reduction Act Notice, see page 2.

Date
Cat. No. 22851L

Form

8850

/

/

(Rev. 3-2009)

1
I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 8850, PAGE 2 of 2
MARGINS: TOP 13mm (1⁄ 2 "), CENTER SIDES. PRINTS: HEAD to HEAD
PAPER: WHITE, WRITING, SUB. 20
INK: BLACK
FLAT SIZE: 216mm (81⁄ 2 ") 3 279mm (11")
PERFORATE: (NONE)
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 8850 (Rev. 3-2009)

Page

2

For Employer’s Use Only

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Telephone no. (

Employer’s name
Street address
City or town, state, and ZIP code

)

-

EIN

©

Telephone no. (

Person to contact, if different from above
Street address
City or town, state, and ZIP code

)

-

If, based on the individual’s age and home address, he or she is a member of group 4 or 6 (as described under Members
©
of Targeted Groups in the separate instructions), enter that group number (4 or 6)

Date applicant:

Gave
information

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Was
offered
job

/

Was
hired

/

/

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Started
job

/

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Complete Only If Box 1 on Page 1 is Checked
State and
county or
parish of
job

Check if the individual was not your employee
on August 28, 2005, and this is the first time
the employee has been hired by you since
August 28, 2005.

provided the
information on

Under penalties of perjury, I declare that the applicant completed 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

©

Privacy Act and
Paperwork Reduction
Act Notice
Section references are to the Internal
Revenue Code.
Section 51(d)(13) permits a prospective
employer to request the applicant to
complete this form and give it to the
prospective employer. The information
will be used by the employer to
complete the employer’s federal tax
return. Completion of this form is
voluntary and may assist members of
targeted groups in securing employment.
Routine uses of this form include giving
it to the state workforce agency (SWA),
which will contact appropriate sources
to confirm that the applicant is a
member of a targeted group. This form
may also be given to the Internal
Revenue Service for administration of
the Internal Revenue laws, to the
Department of Justice for civil and

Title

criminal litigation, to the Department of
Labor for oversight of the certifications
performed by the SWA, and to cities,
states, and the District of Columbia for
use in administering their tax laws. We
may also disclose this information to
other countries under a tax treaty, to
federal and state agencies to enforce
federal nontax criminal laws, or to
federal law enforcement and intelligence
agencies to combat terrorism.
You are not required to provide the
information requested on a form that is
subject to the Paperwork Reduction Act
unless the form displays a valid OMB
control number. Books or records
relating to a form or its instructions must
be retained as long as their contents
may become material in the
administration of any Internal Revenue
law. Generally, tax returns and return
information are confidential, as required
by section 6103.

Date

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The time needed to complete and file
this form will vary depending on
individual circumstances. The estimated
average time is:
Recordkeeping
5 hrs., 30 min.
Learning about the law
or the form
24 min.
Preparing and sending this form
to the SWA
30 min.
If you have comments concerning the
accuracy of these time estimates or
suggestions for making this form
simpler, we would be happy to hear
from you. You can write to the Internal
Revenue Service, Tax Products
Coordinating Committee,
SE:W:CAR:MP:T:T:SP, 1111 Constitution
Ave. NW, IR-6526, Washington, DC
20224.
Do not send this form to this address.
Instead, see When and Where To File in
the separate instructions.

Form
Printed on recycled paper

/

8850

(Rev. 3-2009)