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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16:43 - 12-AUG-2009

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* The Work Opportunity Credit is allowed for employers that hire qualified veterans that have been unemployed for at least 4 weeks.
An increased credit is allowed for veterans and disabled veterans that are unemployed for 6 months or more.

Instructions for Form 8850
(Rev. August 2009)

Department of the Treasury
Internal Revenue Service

November 2011

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

General Instructions
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 and
before 2011, a new targeted group has been added for
certain unemployed 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 details, see
page 2.
• For individuals who begin work after 2008 and before
File Form 8850
2011, 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 September 17, 2009,
employers are required to file Form 8850 with the SWA no
later than October 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.
is
that

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 page 3 for a list of these areas). The employer is not
required to ask employees to furnish any documentary
evidence.

!

Who Should Complete and
the required
Sign the Form
The job applicant gives information to the employer on or
before the day a job offer is made. This information is
by completing
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 (by
October 17, 2009, for unemployed veterans or disconnected
youth hired after 2008 and before September 17, 2009).
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 employee’s
CAUTION 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.

!

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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* A veteran that has been unemployed for a period or periods of at least 4 weeks but less than 6 months in the 1 year period ending on the
hiring date.
* A veteran that has been unemployed for a period or periods of at least 6 months or more in the 1 year period ending on the hiring date.

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 ending 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.
3
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.
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 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. Recipient of SNAP benefits (food stamps). 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 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 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. Unemployed veteran. A veteran hired after 2008 and
before 2011 who:
• Has been discharged or released from active duty in
the U.S. Armed Forces at any time during the 5-year period
ending on the hiring date, and
• Received unemployment compensation under state or
federal law 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.
12. Disconnected youth. An individual hired after 2008
and before 2011 who:
• Is at least age 16 but not yet age 25 on the hiring date;
• During the past 6 months, has not attended or has not
regularly attended any 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 vacation;
• During each consecutive 3-month period within the
past 6 months, was not employed or was employed and
earned an amount less than he or she would have earned
working for the applicable minimum wage 30 hours every
week during the 3-month period; and
• Does not have a certificate of graduation from a
secondary school or a General Education Development
(GED) certificate or has a certificate that was awarded at
least 6 months ago and he or she has not held a job (other
than occasionally) or been admitted to a technical or
post-secondary school since receiving the certificate.

* Entitled to compensation for a service-connected disability and was unemployed for-2a period or periods totaling at least 4 weeks but less than 6
in the 1 year period ending on the hiring date.

months

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“Minimum wage” means the higher of the federal
minimum wage (as defined in 29 U.S.C. 206(a)(1)) or the
generally applicable state minimum wage (if any).
“Secondary school” means an institutional day or
residential school, including a public secondary charter
school, that provides secondary education, as determined
under state law, except that the term does not include any
education beyond grade 12. A General Education
Development (GED) program is not a secondary school for
this purpose.
The terms “technical school” and “post-secondary school”
mean institutions of higher education as defined in 20
U.S.C. 1001; 1002(a)(1), (b), and (c); and 1059c(b)(3).

Jacksonville, FL
Miami/Dade County, FL
Chicago, IL
Gary/Hammond/East Chicago, IN
Boston, MA
Baltimore, MD
Detroit, MI
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,
recipient of SNAP benefits (food stamps), 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

Renewal Communities

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

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

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Atlanta, GA
Chicago, IL
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

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, 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.

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.
Kentucky. The counties of Bell, Caldwell, Floyd, Harlan,
Hickman, Leslie, Letcher, Pike, and Union.

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