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

8850

Form
(Rev. August 2009)

November 2011

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

Department of the Treasury
Internal Revenue Service

©

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
Telephone number (

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

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)

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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.

1

2

2

3

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

but less than
6 months

● I am at least age 16 but not age 25 or older, and:
a During the past 6 months, I have not attended a secondary, technical, or post-secondary school for more than
an average of 10 hours per week, not counting periods during which the school was closed for scheduled
vacations, and

See
INSERT A

5

4

6

5

b During the past 6 months, if I was employed, during each consecutive 3-month period within the past 6 months,
I earned less than I would have earned if I had worked for the applicable minimum wage 30 hours every week
during the 3-month period, and
c I do not have a certificate of graduation from a secondary school or a General Education Development (GED)
certificate or I have a certificate that was awarded at least 6 months ago and I have not held a job (other than
occasionally) or been admitted to a technical or post-secondary school since I received the certificate.
Check here if you are a veteran entitled to compensation for a service-connected disability and, during the past year, and
you were: unemployed
● Discharged or released from active duty in the U.S. Armed Forces, or
during the past year
● Unemployed for a period or periods totaling at least 6 months.
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. 8-2009)

11-2011

INSERT A
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.

11-2011
Form 8850 (Rev. 8-2009)

Page

2

For Employer’s Use Only
Telephone no. (

Employer’s name

)

-

EIN

©

Street address
City or town, state, and ZIP code
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
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.

State and
county or
parish of job

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

©

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
3 hrs., 16 min.
Learning about the law
or the form
46 min.
Preparing and sending this form
to the SWA
42 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.

M:S
Form

8850

(Rev. 8-2009)

11-2011