• Work Opportunity Tax Credit (WOTC) Applicant Questionnaire — Voluntary

    Complete the voluntary questionnaire to help confirm eligibility checks for your employer’s potential tax credit.

  • Why we ask — please read

  • Your employer may be eligible for a federal tax credit for hiring people in certain groups. This form is used only to check that. It is not part of your application, your answers are voluntary, they are kept separate from your application file, and they are not shared with anyone deciding whether to hire you. Declining to answer will not affect your candidacy.

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

  • Form
    8850
    (Rev. March 2016)
    Department of the Treasury
    Internal Revenue Service
  • OMB No. 1545-1500
  • ► 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. Complete only this side.
  • Format: (000) 000-0000.
  • If you are under age 40, enter your date of birth (month, day, year)
     - -
    2 digit month, 2 digit day, 4 digit year

  • Conditional certification details
    ETA 9061 follow-up

  • Date issued
     - -
    2 digit month, 2 digit day, 4 digit year
  • Browse Files
    Drag and drop files here
    Choose a file
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  • 2. Choose any of the boxes that appy to you.

  • Qualified IV-A Details
    ETA 9061 follow-up — Qualified IV-A recipient

  • Veteran + SNAP details
    ETA 9061 follow-up — veteran / SNAP recipient

  • Military service — start date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Military service — end date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Referral Details
    ETA 9061 follow-up — vocational rehabilitation referral

  • Date of referral
     - -
    2 digit month, 2 digit day, 4 digit year

  • SNAP details
    ETA 9061 follow-up — SNAP recipient age 18–39

  • Which applies?

  • Conviction and release details
    ETA 9061 follow-up — qualified ex-felon

  • Date of conviction
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of release from prison, if applicable
     - -
    2 digit month, 2 digit day, 4 digit year
  • If state, which state?

  • SSI details
    ETA 9061 follow-up — SSI recipient

  • Veteran unemployment details
    ETA 9061 follow-up — veteran, 4 weeks to under 6 months unemployed

  • Military service — start date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Military service — end date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Veteran unemployment details
    ETA 9061 follow-up — veteran, 6+ months unemployed

  • Military service — start date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Military service — end date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Disability and discharge details
    ETA 9061 follow-up — disabled veteran, recently discharged

  • Date discharged or released from active duty
     - -
    2 digit month, 2 digit day, 4 digit year

  • Disability and unemployment details
    ETA 9061 follow-up — disabled veteran, 6+ months unemployed

  • Date discharged or released from active duty
     - -
    2 digit month, 2 digit day, 4 digit year

  • TANF details
    ETA 9061 follow-up — TANF / long-term family assistance recipient

  • Long-term unemployment details
    ETA 9061 follow-up — long-term unemployment recipient

  • Date your unemployment period began
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date it ended, if it has
     - -
    2 digit month, 2 digit day, 4 digit year
  • Minnesota
  • North Dakota
  • South Dakota

  • If you are unsure please click this link for additional information:  Counties Map

     

  • Residence confirmation
    ETA 9061 follow-up — designated community resident / summer youth

  • 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.
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  •  
  • Should be Empty: