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8850

Pre-Screening Notice and Certification Request for the

OMB No. 1545-1500

Form

Work Opportunity and Welfare-to-Work Credits

(Rev. October 2002)

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.

Name: __________________________________________________________

Social Security Number: __ __ __ / __ __ / __ __ __ __

Last

First

Street Address Where You Live: _____________________________________________________________________________________

City or Town, State and ZIP Code: ___________________________________________________________________________________

Telephone No. (___ ___ ___) ___ ___ ___ – ___ ___ ___ ___

If you are under age 25, enter your date of birth (month, day, year) ___ ___ / ___ ___ / ___ ___

Work Opportunity Credit

Check here if you received a conditional certification from the state employment security agency (SESA) 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 last 18 months.

• I am a veteran and a member of a family that received food stamps for at least a 3-month period within the last 15

months.

• I was referred here by a rehabilitation agency approved by the state or the Department of Veterans Affairs.

• I am at least age 18 but not age 25 or older and I am a member of a family that:

a. Received food stamps for the last 6 months, or

b. Received food stamps for at least 3 of the last 5 months, but is no longer eligible to receive them.

• Within the past year, I was convicted of a felony or released from prison for a felony and during the last 6 months I

was a member of a low-income family.

• I received supplemental security income (SSI) benefits for any month ending within the last 60 days.

Welfare-to-Work Credit

Check here if you received a conditional certification from the SESA or a participating local agency for the

welfare-to-work credit.

Check here if you are a member of a family that:

• Received TANF payments for at least the last 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 within the last 2 years, or

• Stopped being eligible for TANF payments within the last 2 years because Federal or state law limited the maxi-

mum time those payments could be made.

All Applicants

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. 8-04 Mich. Reprint)

Form 8850 - Pre-Screening Notice And Certification Request For The Work Opportunity And Welfare-To-Work Credits

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