Form 8850 (Rev. January 2012) - Pre-Screening Notice And Certification Request For The Work Opportunity Credit Page 2
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Form 8850 (Rev. 1-2012)
Page
For Employer’s Use Only
Employer’s name
Telephone no.
EIN
PeopleCare Health Services
(970)874-0136
45-4429553
▶
Street address
1565 Hwy 50, Suite B
City or town, state, and ZIP code
Delta, CO 81416
Person to contact, if different from above
Telephone no.
Street address
City or town, state, and ZIP code
If, based on the individual’s age and home address, he or she is a member of group 4 or 6 (as described under Members of
Targeted Groups in the separate instructions), enter that group number (4 or 6) .
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▶
Date applicant:
Gave
Was
Was
Started
information
offered job
hired
job
Under penalties of perjury, I declare that the applicant provided the information on this form on or before the day a job was offered to the applicant and that the
information I have furnished is, to the best of my knowledge, true, correct, and complete. Based on the information the job applicant furnished on page 1, I
believe the individual is a member of a targeted group. I hereby request a certification that the individual is a member of a targeted group.
Employer’s signature
Title
Date
▶
Progam Specialist
Privacy Act and
criminal litigation, to the Department of
The time needed to complete and file
Labor for oversight of the certifications
this form will vary depending on
Paperwork Reduction
performed by the SWA, and to cities,
individual circumstances. The estimated
Act Notice
average time is:
states, and the District of Columbia for
use in administering their tax laws. We
Recordkeeping
.
.
6 hr., 27 min.
may also disclose this information to
Section references are to the Internal
other countries under a tax treaty, to
Learning about the law
Revenue Code.
federal and state agencies to enforce
or the form
.
.
.
.
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. 30 min.
Section 51(d)(13) permits a prospective
federal nontax criminal laws, or to
Preparing and sending this form
employer to request the applicant to
federal law enforcement and intelligence
to the SWA
.
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.
.
.
.
. 37 min.
complete this form and give it to the
agencies to combat terrorism.
prospective employer. The information
If you have comments concerning the
You are not required to provide the
will be used by the employer to
accuracy of these time estimates or
information requested on a form that is
complete the employer’s federal tax
suggestions for making this form
subject to the Paperwork Reduction Act
return. Completion of this form is
simpler, we would be happy to hear from
unless the form displays a valid OMB
voluntary and may assist members of
you. You can write to the Internal
control number. Books or records
targeted groups in securing employment.
Revenue Service, Tax Products
relating to a form or its instructions must
Routine uses of this form include giving
Coordinating Committee,
be retained as long as their contents
it to the state workforce agency (SWA),
SE:W:CAR:MP:T:M:S, 1111 Constitution
may become material in the
which will contact appropriate sources
Ave. NW, IR-6526, Washington, DC
administration of any Internal Revenue
to confirm that the applicant is a
20224.
law. Generally, tax returns and return
member of a targeted group. This form
information are confidential, as required
Do not send this form to this address.
may also be given to the Internal
by section 6103.
Instead, see When and Where To File in
Revenue Service for administration of
the separate instructions.
the Internal Revenue laws, to the
Department of Justice for civil and
8850
Form
(Rev. 1-2012)
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