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

Instructions for Form 8850
(Rev. March 2015)

Department of the Treasury
Internal Revenue Service

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

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

Future Developments

For the latest information about developments related to
Form 8850 and its instructions, such as legislation enacted
after they were published, go to www.irs.gov/form8850.

What's New

The work opportunity credit has been extended to cover
certain individuals who began working for you after
December 31, 2013, and before January 1, 2015. For
information about transitional relief, see When and Where To
File.
Empowerment zone designations generally expired at the
end of 2013. However, the Tax Increase Prevention Act of
2014 provides for an extension of the designations to the end
of 2014. For details, see Empowerment Zones.

Purpose of Form

Employers use Form 8850 to pre-screen and to make a
written request to the state workforce agency (SWA) of the
state in which their business is located (where the employee
works) 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 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. Generally, an employer elects to take the
credit by filing Form 5884, Work Opportunity Credit.
However, a tax-exempt organization that hires a qualified
veteran should report the work opportunity credit on Form
5884-C, Work Opportunity Credit for Qualified Tax-Exempt
Organizations Hiring Qualified Veterans.

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CAUTION

You must receive the certification from the SWA
before you can claim the related credit on Form
5884 or Form 5884-C.

Who Should Complete and
Sign the Form

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.

Mar 17, 2015

Instructions for Employer
When and Where To File

Do not file Form 8850 with the Internal Revenue Service.
Instead, you must generally submit it to the SWA of the state
in which your business is located (where the employee
works) no later than the 28th calendar day after the date the
member of a targeted group begins working for you.
However, for members of targeted groups who began
working for you after December 31, 2013, and before
January 1, 2015, you have until April 30, 2015, to submit
Form 8850 to the SWA.
Although facsimile filing of Form 8850 is permitted, not all
states are equipped to accept a faxed copy of Form 8850.
Contact your state WOTC coordinator as discussed below
and see Notice 2012-13 for details. Notice 2012-13, 2012-9
I.R.B. 421, is available at
www.irs.gov/irb/2012-09_IRB/ar07.html.
Although electronic filing of Form 8850 is permitted, not all
states are equipped to receive Form 8850 electronically.
Contact your state WOTC coordinator as discussed next and
see Announcement 2002-44 and Notice 2012-13 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 must be submitted to
the SWA of the state in which your business is located
(where the employee works).

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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 (for
example, 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.

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

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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.
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.

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 that has received Supplemental
Nutrition Assistance Program (SNAP) benefits (food stamps)
for at least a 3-month period during the 15-month period
ending on the hiring date.
Unemployed for a period or periods totaling at least 4
weeks (whether or not consecutive) but less than 6 months in
the 1-year period ending on the hiring date.
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.
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 or box 5 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 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.

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.

Empowerment Zones

The following paragraphs describe areas that were
designated empowerment zones.
The empowerment zone designations generally
expired at the end of 2013. However, the Tax
CAUTION
Increase Prevention Act of 2014 provides for an
extension of the designations to the end of 2014. To extend
the designations, state and local governments must amend
their nominations for designation to change the termination
date to December 31, 2014. Notice 2015-26 provides
guidance on amending nominations for designation.

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Urban areas. Parts of the following urban areas were
designated empowerment zones. You can find out if your
business or an employee's residence is located within an
urban empowerment zone by using the EZ/RC Address
Locator at www.hud.gov/crlocator.
Baltimore, MD
Boston, MA
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Chicago, IL
Cincinnati, OH
Cleveland, OH
Columbia/Sumter, SC
Columbus, OH
Cumberland County, NJ
Detroit, MI
El Paso, TX
Fresno, CA
Gary/Hammond/East Chicago, IN
Huntington, WV/Ironton, OH
Jacksonville, FL
Knoxville, TN
Los Angeles, CA (city and county)
Miami/Dade County, FL
Minneapolis, MN
New Haven, CT
New York, NY
Norfolk/Portsmouth, VA
Oklahoma City, OK
Philadelphia, PA/Camden, NJ
Pulaski County, AR
San Antonio, TX
Santa Ana, CA
St. Louis, MO/East St. Louis, IL
Syracuse, NY
Tucson, AZ
Yonkers, NY

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.

Rural areas. Parts of the following rural areas were
designated empowerment zones. You can find out if your
business or an employee's residence is located within a rural
empowerment zone by using the EZ/RC Address Locator at
www.hud.gov/crlocator.
Aroostook County, ME (part of Aroostook County)
Desert Communities, CA (part of Riverside County)
Griggs-Steele, ND (part of Griggs County and all of Steele
County)
Kentucky Highlands, KY (part of Wayne County and all of
Clinton and Jackson Counties)
Mid-Delta, MS (parts of Bolivar, Holmes, Humphreys,
Leflore, Sunflower, and Washington Counties)
Middle Rio Grande FUTURO Communities, TX (parts of
Dimmit, Maverick, Uvalde, and Zavala Counties)
Oglala Sioux Tribe, SD (parts of Jackson and Bennett
Counties and all of Shannon County)
Rio Grande Valley, TX (parts of Cameron, Hidalgo, Starr,
and Willacy Counties)
Southernmost Illinois Delta, IL (parts of Alexander and
Johnson Counties and all of Pulaski County)
Southwest Georgia United, GA (part of Crisp County and
all of Dooly County)

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.

Rural Renewal Counties

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.

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.

Nevada. The counties of Esmeralda, Lander, and Mineral.

Alaska. The census areas of Aleutians West,
Wrangell-Petersburg, and Yukon-Koyukuk.

New Hampshire. Coos County.
New Mexico. The counties of Harding and Quay.
New York. The counties of Clinton and Montgomery.
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McPherson, Miner, Perkins, Potter, Sanborn, Spink, Tripp,
and Walworth.

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.

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.

Ohio. The counties of Crawford, Monroe, Paulding, Seneca,
and Van Wert.

Virginia. The counties of Buchanan, Dickenson, Highland,
and Lee, and the independent cities of Clifton Forge,
Covington, Norton, and Staunton.

Oklahoma. The counties of Alfalfa, Beaver, Cimarron,
Custer, Dewey, Ellis, Grant, Greer, Harmon, Harper, Kiowa,
Major, Roger Mills, Seminole, Tillman, and Woodward.

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

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,

Wyoming. The counties of Carbon and Niobrara.

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