Pre-Screening Notice and Certification Request for the Work Opportunity and Welfare-to-Work Credits

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Instructions for Form 8850

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Instructions for Form 8850

Department of the Treasury
Internal Revenue Service

(Rev. March 2009)
Pre-Screening Notice and Certification Request for the Work Opportunity Credit

General Instructions

Who Should Complete and
Sign the Form

Section references are to the Internal Revenue Code
unless otherwise noted.

What’s New

• The targeted group for Hurricane Katrina employees
has been extended to cover certain employees hired
after August 27, 2007, and before August 28, 2009.
• For certain veterans who begin work after 2008, the
qualified veterans group is expanded to include veterans
who were discharged or released from active duty in the
U.S. Armed Forces during the 5-year period ending on
the hiring date and received unemployment
compensation for at least 4 weeks during the 1-year
period ending on the hiring date.
• For individuals who begin work after 2008, a new
targeted group has been added for disconnected youth.
For details, see page 2.
• For unemployed veterans and disconnected youth
(discussed above) hired before July 17, 2009, employers
are required to file Form 8850 with the SWA no later than
August 17, 2009.
• The food stamp program has been renamed the
Supplemental Nutrition Assistance Program (SNAP).
• Parts of Washington, DC will continue to be treated as
an empowerment zone until the end of 2009. See page 3.

Purpose of Form
Employers use Form 8850 to pre-screen and to make a
written request to their state workforce agency (SWA)
(unless the employee checks only the Hurricane Katrina
employee box) to certify an individual as a member of a
targeted group for purposes of qualifying for the work
opportunity credit.
Submitting Form 8850 to the SWA (unless the
employee checks only the Hurricane Katrina employee
box) is but one step in the process of qualifying for the
work opportunity credit. The state work opportunity tax
credit (WOTC) coordinator for the SWA must certify the
job applicant is a member of a targeted group. After
starting work, the employee must meet the minimum
number-of-hours-worked requirement for the work
opportunity credit. The employer elects to take the credit
by filing Form 5884, Work Opportunity Credit.
The certification requirements described above do
not apply to Hurricane Katrina employees. For an
CAUTION employer of a Hurricane Katrina employee, this
form is used to accept reasonable evidence that the
worker is a Hurricane Katrina employee. It is the
employer’s responsibility to ascertain that the place
where the employee lived on August 28, 2005, (the
address on line 1 of the form) is in fact in the Gulf
Opportunity Zone (core disaster area) (see pages 2 and
3 for a list of these areas). The employer is not required
to ask employees to furnish any documentary evidence.

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The job applicant gives information to the employer on or
before the day a job offer is made. This information is
entered on Form 8850. Based on the applicant’s
information, the employer determines whether or not he
or she believes the applicant is a member of a targeted
group (as defined under Members of Targeted Groups). If
the employer believes the applicant is a member of a
targeted group, the employer completes the rest of the
form no later than the day the job offer is made. Both the
job applicant and the employer must sign Form 8850 no
later than the date for submitting the form to the SWA.

Instructions for Employer
When and Where to File
Do not file Form 8850 with the Internal Revenue Service.
Instead, if required, file it with your SWA no later than the
28th day after the job applicant begins work for you (see
What’s New for an exception that applies to two recently
added targeted groups). Although electronic filing of
Form 8850 is permitted, at the time these instructions
were published, Alabama and Colorado were the only
states equipped to receive Form 8850 electronically. See
Announcement 2002-44 for details. You can find
Announcement 2002-44 on page 809 of Internal
Revenue Bulletin 2002-17 at
www.irs.gov/pub/irs-irbs/irb02-17.pdf.
To get the name, address, phone and fax numbers,
and email address of the WOTC coordinator for your
state, visit the Department of Labor Employment and
Training Administration (ETA) website at
www.doleta.gov/business/Incentives/opptax.
Never attach Form 8850 to a tax return or
otherwise send it to the IRS, regardless of the
CAUTION employee’s targeted group. Form 8850 should be
filed with the SWA unless the employee checks only the
Hurricane Katrina employee box, in which case the
employer should keep the Form 8850 for its records.

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Additional Requirements for
Certification
In addition to filing Form 8850, you must complete and
send to your state WOTC coordinator either:
• ETA Form 9062, Conditional Certification Form, if the
job applicant received this form from a participating
agency (e.g., the Jobs Corps) or
• ETA Form 9061, Individual Characteristics Form, if the
job applicant did not receive a conditional certification.
You can get ETA Form 9061 from your local public
employment service office or you can download it from
the ETA website at
www.doleta.gov/business/Incentives/opptax.

Cat. No. 24833J

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Instructions for Form 8850

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substantial handicap to employment and who was
referred to the employer upon completion of (or while
receiving) rehabilitation services by a rehabilitation
agency approved by the state, an employment network
under the Ticket to Work program, or the Department of
Veterans Affairs.
6. Summer youth employee. An individual who:
• Performs services for the employer between May 1
and September 15,
• Is at least age 16 but not yet age 18 on the hiring
date (or if later, on May 1),
• Has never worked for the employer before, and
• Lives within an empowerment zone or renewal
community.
7. SNAP benefits (food stamps) recipient. An
individual who:
• Is at least age 18 but not yet age 40 on the hiring
date, and
• Is a member of a family that —
a. Has received SNAP benefits (food stamps) for the
6-month period ending on the hiring date, or
b. Is no longer eligible for such assistance under
section 6(o) of the Food Stamp Act of 1977, but the
family received SNAP benefits (food stamps) for at least
3 months of the 5-month period ending on the hiring date.
8. SSI recipient. An individual who is receiving
supplemental security income benefits under title XVI of
the Social Security Act (including benefits of the type
described in section 1616 of the Social Security Act or
section 212 of Public Law 93-66) for any month ending
during the 60-day period ending on the hiring date.
9. Long-term family assistance recipient. An
individual who is a member of a family that:
• Has received TANF payments for at least 18
consecutive months ending on the hiring date, or
• Receives TANF payments for any 18 months
(whether or not consecutive) 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 because
federal or state law limits the maximum period such
assistance is payable and the individual is hired not more
than 2 years after such eligibility ended.
10. Hurricane Katrina employee. A Hurricane Katrina
employee is a person who, on August 28, 2005, had a
main home in the Gulf Opportunity (GO) Zone (core
disaster area) and, during a 4-year period beginning on
this date, is hired to perform services principally in the
GO Zone. Certification does not apply to this group.
11. Disconnected youth. An individual hired after
2008 who is at least age 16 but not age 25 or older on
the hiring date and during the past 6 months:
• Has not attended or has not regularly attended
(attended fewer than half of the required days or hours)
any high school, technical school, or college;
• Was not employed or was employed and earned
less than an employee working for minimum wage would
have earned working 30 hours a week during the entire
6-month period, and
• Either does not have a high school diploma or
General Education Development Certificate (GED) or has
a diploma or GED but has not completed more than one
semester or quarter (or the equivalent) at a technical
school or college.

Recordkeeping
Keep copies of Forms 8850, any transmittal letters that
you submit to your state WOTC coordinator, and
certification letters you receive from your WOTC
coordinator as long as they may be needed for the
administration of the provisions relating to the work
opportunity credit. Records that support the credit usually
must be kept for 3 years from the date any income tax
return claiming the credit is due or filed, whichever is
later.

Members of Targeted Groups
A job applicant may be certified as a member of a
targeted group if he or she is described in one of the
following groups.
1. Qualified IV-A recipient. An individual who is a
member of a family receiving assistance under a state
plan approved under part A of title IV of the Social
Security Act relating to Temporary Assistance for Needy
Families (TANF). The assistance must be received for
any 9 months during the 18-month period that ends on
the hiring date.
2. Qualified veteran. A veteran who is any of the
following.
• A member of a family receiving assistance under the
Supplemental Nutrition Assistance Program (SNAP)
(food stamps) for at least a 3-month period during the
15-month period ending on the hiring date.
• Entitled to compensation for a service-connected
disability and is hired not more than 1 year after being
discharged or released from active duty in the U.S.
Armed Forces.
• Entitled to compensation for a service-connected
disability and was unemployed for a period or periods
totaling at least 6 months (whether or not consecutive) in
the 1-year period ending on the hiring date.
Note. Requesting the information in box 4 of Form 8850
is an exception to the Americans with Disabilities Act’s
prohibition on pre-offer disability-related inquiries. The
purpose of this request is to support the hiring of certain
disabled veterans, which will entitle the employer to a
larger work opportunity credit than the hiring of other
targeted group members.
• Hired after 2008 but not more than 5 years after
being discharged or released from active duty in the U.S.
Armed Forces and received unemployment
compensation for at least 4 weeks during the 1-year
period ending on the hiring date.
To be considered a veteran, the applicant must:
• Have served on active duty (not including training) in
the Armed Forces of the United States for more than 180
days or have been discharged or released from active
duty for a service-connected disability, and
• Not have a period of active duty (not including
training) of more than 90 days that ended during the
60-day period ending on the hiring date.
3. Qualified ex-felon. An ex-felon who has been
convicted of a felony under any federal or state law, and
is hired not more than 1 year after the conviction or
release from prison for that felony.
4. Designated community resident. An individual
who is at least age 18 but not yet age 40 on the hiring
date and lives within an empowerment zone, renewal
community, or rural renewal county (defined later).
5. Vocational rehabilitation referral. An individual
who has a physical or mental disability resulting in a
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Minneapolis, MN
St. Louis, MO/East St. Louis, IL
Cumberland County, NJ
New York, NY
Syracuse, NY
Yonkers, NY
Cincinnati, OH
Cleveland, OH
Columbus, OH
Oklahoma City, OK
Philadelphia, PA/Camden, NJ
Columbia/Sumter, SC
Knoxville, TN
El Paso, TX
San Antonio, TX
Norfolk/Portsmouth, VA
Huntington, WV/Ironton, OH
Washington, DC. Under section 1400, parts of
Washington, DC, are treated as an empowerment zone.
This treatment will generally remain in effect until the end
of 2009. For details, use the RC/EZ/EC Address Locator
at www.hud.gov/crlocator or see Notice 98-57 on page 9
of Internal Revenue Bulletin 1998-47 at www.irs.gov/pub/
irs-irbs/irb98-47.pdf.
Rural areas. Parts of the following rural areas are
empowerment zones. You can find out if your business or
an employee’s residence is located within a rural
empowerment zone by using the RC/EZ/EC Address
Locator at www.hud.gov/crlocator or by calling
1-800-998-9999.
• Desert Communities, CA (part of Riverside County)
• Southwest Georgia United, GA (part of Crisp County
and all of Dooly County)
• Southernmost Illinois Delta, IL (parts of Alexander and
Johnson Counties and all of Pulaski County)
• Kentucky Highlands, KY (part of Wayne County and all
of Clinton and Jackson Counties)
• Aroostook County, ME (part of Aroostook County)
• Mid-Delta, MS (parts of Bolivar, Holmes, Humphreys,
Leflore, Sunflower, and Washington Counties)
• Griggs-Steele, ND (part of Griggs County and all of
Steele County)
• Oglala Sioux Tribe, SD (parts of Jackson and Bennett
Counties and all of Shannon County)
• Middle Rio Grande FUTURO Communities, TX (parts
of Dimmit, Maverick, Uvalde, and Zavala Counties)
• Rio Grande Valley, TX (parts of Cameron, Hidalgo,
Starr, and Willacy Counties)

Member of a Family
With respect to the qualified IV-A recipient, qualified
veteran, SNAP benefits (food stamps) recipient, and
long-term family assistance recipient, an individual whose
family receives assistance for the requisite period meets
the family assistance requirement of the applicable group
if the individual is included on the grant (and thus
receives assistance) for some portion of the specified
period.

Gulf Opportunity (GO) Zone (Core
Disaster Area)
The GO Zone (also called the core disaster area) covers
the portion of the Hurricane Katrina disaster area
determined by the Federal Emergency Management
Agency (FEMA) to be eligible for either individual only or
both individual and public assistance from the Federal
Government. The GO Zone covers the following areas in
three states.
Alabama. The counties of Baldwin, Choctaw, Clarke,
Greene, Hale, Marengo, Mobile, Pickens, Sumter,
Tuscaloosa, and Washington.
Louisiana. The parishes of Acadia, Ascension,
Assumption, Calcasieu, Cameron, East Baton Rouge,
East Feliciana, Iberia, Iberville, Jefferson, Jefferson
Davis, Lafayette, Lafourche, Livingston, Orleans,
Plaquemines, Pointe Coupee, St. Bernard, St. Charles,
St. Helena, St. James, St. John the Baptist, St. Martin,
St. Mary, St. Tammany, Tangipahoa, Terrebonne,
Vermilion, Washington, West Baton Rouge, and West
Feliciana.
Mississippi. The counties of Adams, Amite, Attala,
Choctow, Claiborne, Clarke, Copiah, Covington, Forrest,
Franklin, George, Greene, Hancock, Harrison, Hinds,
Holmes, Humphreys, Jackson, Jasper, Jefferson,
Jefferson Davis, Jones, Kemper, Lamar, Lauderdale,
Lawrence, Leake, Lincoln, Lowndes, Madison, Marion,
Neshoba, Newton, Noxubee, Oktibbeha, Pearl River,
Perry, Pike, Rankin, Scott, Simpson, Smith, Stone,
Walthall, Warren, Wayne, Wilkinson, Winston, and
Yazoo.

Empowerment Zones
The following paragraphs describe current designations
of empowerment zones. The designations will generally
remain in effect until the end of 2009.
Urban areas. Parts of the following urban areas are
empowerment zones. You can find out if your business or
an employee’s residence is located within an urban
empowerment zone by using the RC/EZ/EC Address
Locator at www.hud.gov/crlocator or by calling
1-800-998-9999.
• Pulaski County, AR
• Tucson, AZ
• Fresno, CA
• Los Angeles, CA (city and county)
• Santa Ana, CA
• New Haven, CT
• Jacksonville, FL
• Miami/Dade County, FL
• Chicago, IL
• Gary/Hammond/East Chicago, IN
• Boston, MA
• Baltimore, MD
• Detroit, MI

Renewal Communities
Parts of the following areas are designated as renewal
communities. The designations will generally remain in
effect until the end of 2009. You can find out if your
business or an employee’s residence is located within a
renewal community by using the RC/EZ/EC Address
Locator at www.hud.gov/crlocator or by calling
1-800-998-9999.
• Greene-Sumter County, AL
• Mobile County, AL
• Southern Alabama
• Los Angeles, CA
• Orange Grove, CA
• Parlier, CA
• San Diego, CA
• San Francisco, CA
• Atlanta, GA
• Chicago, IL
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Eastern KY
Central Louisiana
New Orleans, LA
Northern Louisiana
Ouachita Parish, LA
Lawrence, MA
Lowell, MA
Detroit, MI
Flint, MI
West Central Mississippi
Turtle Mountain Band of Chippewa, ND
Camden, NJ
Newark, NJ
Buffalo-Lackawanna, NY
Jamestown, NY
Niagara Falls, NY
Rochester, NY
Schenectady, NY
Hamilton, OH
Youngstown, OH
Philadelphia, PA
Charleston, SC
Chattanooga, TN
Memphis, TN
Corpus Christi, TX
El Paso County, TX
Burlington, VT
Tacoma, WA
Yakima, WA
Milwaukee, WI

Kentucky. The counties of Bell, Caldwell, Floyd, Harlan,
Hickman, Leslie, Letcher, Pike, and Union.
Louisiana. The parishes of Bienville, Claiborne,
Franklin, Jackson, Morehouse, St. Mary, Tensas,
Vernon, and Webster.
Maine. The counties of Aroostook and Piscataquis.
Michigan. The counties of Gogebic, Marquette, and
Ontonagon.
Minnesota. The counties of Big Stone, Chippewa,
Cottonwood, Faribault, Jackson, Kittson, Koochiching,
Lac Qui Parle, Lincoln, Marshall, Martin, Murray,
Norman, Pipestone, Red Lake, Redwood, Renville,
Stevens, Traverse, Wilkin, and Yellow Medicine.
Mississippi. The counties of Adams, Coahoma,
Humphreys, Montgomery, Quitman, Sharkey,
Tallahatchie, and Washington.
Missouri. The counties of Atchison, Carroll, Chariton,
Clark, Holt, Knox, Mississippi, New Madrid, Pemiscot,
and Worth.
Montana. The counties of Carter, Daniels, Dawson,
Deer Lodge, Fallon, Garfield, Hill, Liberty, McCone,
Petroleum, Phillips, Powder River, Prairie, Richland,
Roosevelt, Rosebud, Sheridan, Valley, and Wibaux.
Nebraska. The counties of Antelope, Banner, Boone,
Box Butte, Boyd, Burt, Cedar, Chase, Deuel, Dundy,
Fillmore, Franklin, Garden, Garfield, Greeley, Hayes,
Hitchcock, Holt, Jefferson, Johnson, Logan, Nance,
Nemaha, Nuckolls, Pawnee, Perkins, Red Willow,
Richardson, Rock, Sheridan, Sherman, Thayer, Thomas,
Valley, Webster, and Wheeler.
Nevada. The counties of Esmeralda, Lander, and
Mineral.
New Hampshire. Coos County.
New Mexico. The counties of Harding and Quay.
New York. The counties of Clinton and Montgomery.
North Dakota. The counties of Adams, Barnes, Benson,
Billings, Bottineau, Burke, Cavalier, Dickey, Divide, Dunn,
Eddy, Emmons, Foster, Golden Valley, Grant, Griggs,
Hettinger, Kidder, LaMoure, Logan, McHenry, McIntosh,
McKenzie, McLean, Mercer, Mountrail, Nelson, Oliver,
Pembina, Pierce, Ramsey, Ransom, Renville, Sargent,
Sheridan, Slope, Stark, Steele, Stutsman, Towner, Traill,
Walsh, Wells, and Williams.
Ohio. The counties of Crawford, Monroe, Paulding,
Seneca, and Van Wert.
Oklahoma. The counties of Alfalfa, Beaver, Cimarron,
Custer, Dewey, Ellis, Grant, Greer, Harmon, Harper,
Kiowa, Major, Roger Mills, Seminole, Tillman, and
Woodward.
Pennsylvania. The counties of Venango and Warren.
South Carolina. Marlboro County.
South Dakota. The counties of Aurora, Campbell,
Clark, Day, Deuel, Douglas, Faulk, Grant, Gregory,
Haakon, Hand, Harding, Hutchinson, Jones, Kingsbury,
Marshall, McPherson, Miner, Perkins, Potter, Sanborn,
Spink, Tripp, and Walworth.
Texas. The counties of Andrews, Bailey, Baylor,
Borden, Briscoe, Brooks, Castro, Cochran, Coleman,
Collingsworth, Cottle, Crane, Culberson, Deaf Smith,
Dimmit, Eastland, Fisher, Floyd, Foard, Gray, Hall,
Hardeman, Haskell, Hemphill, Hockley, Hutchinson,
Kenedy, Kent, Knox, Lamb, Martin, McCulloch, Morris,
Nolan, Oldham, Reagan, Reeves, Refugio, Roberts,

Rural Renewal Counties
A rural renewal county is a county in a rural area that lost
population during the 5-year periods 1990 through 1994
and 1995 through 1999. Rural renewal counties are listed
below.
Alabama. The counties of Butler, Dallas, Macon, Perry,
Sumter, and Wilcox.
Alaska. The census areas of Aleutians West,
Wrangell-Petersburg, and Yukon-Koyukuk.
Arkansas. The counties of Arkansas, Chicot, Clay,
Desha, Jackson, Lafayette, Lee, Little River, Monroe,
Nevada, Ouachita, Phillips, Union, and Woodruff.
Colorado. The counties of Cheyenne, Kiowa, and San
Juan.
Georgia. The counties of Randolph and Stewart.
Illinois. The counties of Alexander, Edwards, Franklin,
Gallatin, Greene, Hancock, Hardin, Jasper, Knox,
McDonough, Montgomery, Pulaski, Randolph, Richland,
Scott, Warren, Wayne, and White.
Indiana. Perry County.
Iowa. The counties of Adair, Adams, Appanoose,
Audubon, Butler, Calhoun, Cass, Cherokee, Clay,
Clayton, Emmet, Floyd, Franklin, Fremont, Hancock,
Humboldt, Ida, Keokuk, Kossuth, Montgomery, Osceola,
Palo Alto, Pocahontas, Poweshiek, Sac, Taylor, Union,
Wayne, Winnebago, and Worth.
Kansas. The counties of Atchison, Barber, Barton,
Brown, Clay, Cloud, Comanche, Decatur, Edwards, Elk,
Ellsworth, Gove, Graham, Greeley, Greenwood, Harper,
Hodgeman, Jewell, Kiowa, Labette, Lane, Lincoln,
Marshall, Mitchell, Montgomery, Ness, Osborne, Phillips,
Rawlins, Republic, Rooks, Rush, Russell, Scott,
Sheridan, Sherman, Smith, Stafford, Trego, Wallace,
Washington, Wichita, and Woodson.
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Scurry, Stonewall, Terrell, Terry, Upton, Ward, Wheeler,
Wilbarger, Winkler, Yoakum, and Zavala.
Virginia. The counties of Buchanan, Dickenson,
Highland, and Lee and the independent cities of Clifton
Forge, Covington, Norton, and Staunton.

West Virginia. The counties of Calhoun, Gilmer, Logan,
McDowell, Mercer, Mingo, Summers, Tucker, Webster,
Wetzel, and Wyoming.
Wyoming. The counties of Carbon and Niobrara.

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