Form 8850 - Big Lots Employment Application (Page 4 of 4) in pdf

Form 8850 (Rev. 8-2009)

Page

For Employer’s Use Only

(

)

1186811

Employer’s name

Telephone no.

EIN

Street address

City or town, state, and ZIP code

(

)

Elizabeth Henricks c/o First Advantage

888

570

4455

Person to contact, if different from above

Telephone no.

First Advantage, 9025 N. River Rd., Suite 300

Street address

Indianapolis, IN 46240

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)

Date applicant:

Gave

Was

Started

information

offered job

hired

job

Complete Only If Box 1 on Page 1 is Checked

Check if the individual was not your employee

State and

on August 28, 2005, and this is the first time

county or

the employee has been hired by you since

parish of job

August 28, 2005.

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

Privacy Act and

The time needed to complete and file

criminal litigation, to the Department of

this form will vary depending on

Labor for oversight of the certifications

Paperwork Reduction

individual circumstances. The estimated

performed by the SWA, and to cities,

Act Notice

average time is:

states, and the District of Columbia for

use in administering their tax laws. We

Recordkeeping

3 hrs., 16 min.

Section references are to the Internal

may also disclose this information to

Learning about the law

Revenue Code.

other countries under a tax treaty, to

or the form

46 min.

federal and state agencies to enforce

Section 51(d)(13) permits a prospective

Preparing and sending this form

federal nontax criminal laws, or to

employer to request the applicant to

to the SWA

42 min.

federal law enforcement and intelligence

complete this form and give it to the

agencies to combat terrorism.

If you have comments concerning the

prospective employer. The information

accuracy of these time estimates or

will be used by the employer to

You are not required to provide the

suggestions for making this form

complete the employer’s federal tax

information requested on a form that is

simpler, we would be happy to hear

return. Completion of this form is

subject to the Paperwork Reduction Act

from you. You can write to the Internal

voluntary and may assist members of

unless the form displays a valid OMB

Revenue Service, Tax Products

targeted groups in securing employment.

control number. Books or records

Coordinating Committee,

Routine uses of this form include giving

relating to a form or its instructions must

SE:W:CAR:MP:T:T:SP, 1111 Constitution

it to the state workforce agency (SWA),

be retained as long as their contents

Ave. NW, IR-6526, Washington, DC

which will contact appropriate sources

may become material in the

20224.

to confirm that the applicant is a

administration of any Internal Revenue

member of a targeted group. This form

law. Generally, tax returns and return

Do not send this form to this address.

may also be given to the Internal

information are confidential, as required

Instead, see When and Where To File in

Revenue Service for administration of

by section 6103.

the separate instructions.

the Internal Revenue laws, to the

Department of Justice for civil and

8850

Form

(Rev. 8-2009)

Form 8850 - Big Lots Employment Application Page 4

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