Form 8850 - Pre-Screening Notice and Certification Request for the Work Opportunity and Welfare-to-Work Credits

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 8850 Pre-Screening Notice and Certification Request for the Work Opportunity and Welfare-to-Work Credits	Form	Modified	Repair queued
Notice 2015-13.pdf	Supplementary Document	Uploaded 2015-04-17	Available
Non-Display_Expiration_Date_Statement[1].docx	Supplementary Document	Uploaded 2015-03-03	Available
8850.Supporting Statement.doc	Supporting Statement A	Uploaded 2015-04-30	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
18507	Pre-Screening Notice and Certification Request for the Work Opportunity and Welfare-to-Work Credits	Form	Modified

ICR Details

OMB Control No: 1545-1500	ICR Reference No: 201503-1545-006
Status: Historical Active	Previous ICR Reference No: 201111-1545-031
Agency/Subagency: TREAS/IRS	Agency Tracking No:
Title: Form 8850 - Pre-Screening Notice and Certification Request for the Work Opportunity and Welfare-to-Work Credits
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/21/2015
	Date Received in OIRA: 04/30/2015
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2018	36 Months From Approved	11/30/2015
Responses	440,000	0	440,000
Time Burden (Hours)	3,242,800	0	3,335,200
Cost Burden (Dollars)	0	0	0

---

Abstract: A job applicant completes and signs, under penalties of perjury, the top portion of the form to indicate that he or she is a member of a targeted group. If the employer has a belief that the applicant is a member of a targeted group, the employer signs the other portion of the form under penalties of perjury and submits it to their state workforce agency (SWA) as part of a written request for certification.

---

Authorizing Statute(s): US Code: 26 USC 51 Name of Law: Amount of credit
  

Citations for New Statutory Requirements: PL: Pub.L. 113 - 295 119 Name of Law: The Tax Increase Prevention Act of 2014
PL: Pub.L. 113 - 295 139 Name of Law: The Tax Increase Prevention Act of 2014

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 7077	02/09/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 24317	04/30/2015
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Pre-Screening Notice and Certification Request for the Work Opportunity and Welfare-to-Work Credits	8850	Pre-Screening Notice and Certification Request for the Work Opportunity and Welfare-to-Work Credits

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	440,000	440,000	0	0	0	0
Annual Time Burden (Hours)	3,242,800	3,335,200	-92,400	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: There will be a decrease of 92,400 hours in the total burden for this collection due to a reduction of code section referenced in the instruction.

---

Annual Cost to Federal Government: $1,604

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Yes

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 04/30/2015

---