Form 8850 - Pre-Screening Notice And Certification Request For The Work Opportunity Credit - 2009

Download a blank fillable Form 8850 - Pre-Screening Notice And Certification Request For The Work Opportunity Credit - 2009 in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form 8850 - Pre-Screening Notice And Certification Request For The Work Opportunity Credit - 2009 with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

8850

Pre-Screening Notice and Certification Request for

Form

the Work Opportunity Credit

OMB No. 1545-1500

(Rev. August 2009)

Department of the Treasury

See separate instructions.

Internal Revenue Service

Job applicant: Fill in the lines below and check any boxes that apply. Complete only this side.

Your name

Social security number

Street address where you live

City or town, state, and ZIP code

Telephone number (

)

County

If you are under age 40, enter your date of birth (month, day, year)

Check here if you are completing this form before August 28, 2009, and you lived in the area impacted by Hurricane Katrina

on August 28, 2005. If so, please enter the address, including county or parish and state where you lived at that time.

Check here if you received a conditional certification from the state workforce agency (SWA) or a participating local agency

for the work opportunity credit.

Check 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:

Received SNAP benefits (food stamps) for the past 6 months, or

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 discharged or released from active duty in the U.S. Armed Forces during the past 5 years

and, for at least 4 weeks during the past year, I received unemployment compensation.

I am at least age 16 but not age 25 or older, and:

During the past 6 months, I have not attended a secondary, technical, or post-secondary school for more than

an average of 10 hours per week, not counting periods during which the school was closed for scheduled

vacations, and

b During the past 6 months, if I was employed, during each consecutive 3-month period within the past 6 months,

I earned less than I would have earned if I had worked for the applicable minimum wage 30 hours every week

during the 3-month period, and

c I do not have a certificate of graduation from a secondary school or a General Education Development (GED)

certificate or I have a certificate that was awarded at least 6 months ago and I have not held a job (other than

occasionally) or been admitted to a technical or post-secondary school since I received the certificate.

Check here if you are a veteran entitled to compensation for a service-connected disability and, during the past year,

you were:

Discharged or released from active duty in the U.S. Armed Forces, or

Unemployed for a period or periods totaling at least 6 months.

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.

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.

Job applicant’s signature

Date

8850

For Privacy Act and Paperwork Reduction Act Notice, see page 2.

Cat. No. 22851L

Form

(Rev. 8-2009)