Tax Credit Packet 8850/9061

Work Opportunity Credit Packet

Please answer all questions to complete this packet. This information will not be used to make employment decisions or negatively impact you or benefits you may receive. All information submitted is confidential.

Department of the Treasury IRS form 8850 & ETA Form 9061. Pre-Screening Notice and Certification Request for the Work Opportunity Credit. Information about Form 8850 and its separate instructions is at www.irs.gov/form8850.
First Name*
Middle Initial*
Last Name*
Your social security number*
Address*

Street address where you live

Street Address Line 2

City or town state and ZIP codeState / Province

Postal / Zip Code
County (NOT Country)*
Telephone number*
Enter your date of birth*

MonthDayYear
Date
Have you worked for Mid Oregon Personnel before?*

YesNo
Signature

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 applicants signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date

INDIVIDUAL CHARACTERISTICS FORM
Are you 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?*

YesNo
Who is the primary benefits recipient?
What is the city and state(s) where benefits were received?

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

YesNo
Are you receiving Supplemental Nutrition Assistance Program (SNAP) benefits?*

YesNo
Who is the primary family member receiving Supplemental Nutrition Assistance Program (SNAP) benefits?*
What is the city and state(s) where benefits were received?*

Are you a Vocational Rehabilitation Referral?*

YesNo
Who were you referred by? (If not one of the following, please select NO to the question above)*

Rehabilitation agency approved by the stateEmployment Network under the Ticket to Work ProgramDepartment of Veterans Affairs

Are you a Qualified Summer Youth Employee? (Must be at least 16 years old, but under 18 on the date of hire or on May 1, whichever is later, AND is only employed between May 1 and September 15 (was not employed prior to May 1) AND resides in an Empowerment Zone (EZ), enterprise community or renewal community.

YesNo

Are you receiving SNAP benefits?*

YesNo
Are you least 18 years old and under 40 and a member of a family that received SNAP benefits for either the previous 6 months or at least 3 of the previous 5 months?*

YesNo
Who is the primary benefits recipient?*
What is the city and state(s) where the benefits were received?*

Did you receive SSI (supplemental security income) benefits for any month ending during the past 60 days?*

YesNo

Are you a member of a family that 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?*

YesNo
Enter name of the primary benefits recipient:*
Enter the city and state(s) where benefits were received:

Are you an individual who has been unemployed for not less than 27 consecutive weeks and who received unemployment compensation during some or all of the unemployment period.*

YesNo
Enter the city and state(s) where Unemployment Insurance records/wage records were filed:*

I certify that this information is true and correct to the best of my knowledge. I understand that the information above may be subject to verification.
Please indicate who is signing this form?

Job applicantParent Guardian (if job applicant is a minor)SWA/Participating Agency
Signature

Powered by Jotform SignClear
Should be Empty:

Work Opportunity Credit Packet