8850 - Pre-Screening Notice and Certification Request for the Work Opportunity Credit

Pre-Screening Notice and Certification Request for the Work Opportunity Credit
Department of the Treasury Internal Revenue Service

Information about Form 8850 and its separate instructions is at www.irs.gov/form8850.

Job applicant: Fill in the lines below and check any boxes that apply.
Name*

First NameLast Name
Email*
example@example.com
Social security number*
Street address where you live*
City or town, state, and Zip code*

Street Address

Street Address Line 2

CityState

Zip Code
County*
Telephone number*
If you are under age 40, enter your date of birth (month, day, year)

MonthDayYear
Date
Check here if you received a conditional certification from the state workforce agency (SWA) or a participating local agencyCheck 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 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 unemployed for a period or periods totaling at least 4 weeks but less than 6 months during the past year.
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.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 yearCheck here if you are a veteran entitled to compensation for a service-connected disability and you were unemployed for a period or periods totaling at least 6 months during the past year.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.
Check here if you are in a period of unemployment that is at least 27 consecutive weeks and for all or part of that period you received unemployment compensation.
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.
Signature*

Clear
Date

MonthDayYear
Date
For Privacy Act and Paperwork Reduction Act Notice, see below.
Please Fill in to the Best of Your Ability!
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
First Work Date

MonthDayYear
Date
1. Have you worked for this employer before?*

YesNo
2a. Are you a member of a family that received SNAP (Food Stamps) benefits during the past 6 months?*

YesNo
2b. Did you get SNAP for 3 out of the past 5 months but are no longer getting them?*

YesNo
If YES to either question, enter the name of the primary recipient
and the City and State where benefits were received
3 a. Are you a member of a family that received TANF/Welfare for the last 18 months before you were hired?*

YesNo
3 b. OR, did you start receiving TANF for any 18 months after August 5, 1997 which ended within 2 years before you were hired?*

YesNo
3 c. OR, you are no longer receiving TANF/Welfare because you reached the maximum allowable?*

YesNo
3 d. OR, did you receive TANF/Welfare for 9 months out of the past 18 months?*

YesNo
If YES to either question, enter the name of the primary recipient
and the City and State where benefits were received
4. Did you receive Supplemental Security Income (SSI) benefits for any month ending within 60 days before you were hired?*

YesNo
5. Were you Unemployed for the past 27 weeks and you received any unemployment benefits?*

YesNo
IF YES, what State did you receive unemployment compensation in?
6a. Were you referred by a Network under the Ticket to Work program?*

YesNo
6b. OR, by a Vocational Rehabilitation Agency approved by a State?*

YesNo
7. Were you convicted of a felony or released from prison after a felony conviction during the year before you were hired?*

YesNo
if Yes, enter the date of conviction

MonthDayYear
Date
if Yes, enter the date of release

MonthDayYear
Date
What kind of conviction was it?

FederalState
8. Are you a veteran of the U.S. Armed Forces?*

YesNo
Signature*

Clear
Privacy Act and Paperwork Reduction Act Notice
Section references are to the Internal Revenue Code. Section 51(d13) 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

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.

The time needed to complete and file this form will vary depending on individual circumstances. The estimated average time is:

Recordkeeping .. 6 hr., 27 min.

Learning about the law or the form ....... 24 min

Preparing and sending this form to the SWA ....... 31 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 send us comments from www.irs.gov/formspubs. Click on “More Information” and then on “Give us feedback.” Or you can send your comments to: Internal Revenue Service Tax Forms and Publications 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.
Should be Empty:

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

Signature—All Applicants Must Sign

Please Fill in to the Best of Your Ability!

Privacy Act and Paperwork Reduction Act Notice