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Form 8850 (Rev 10-02) Mich. Reprint

For Employer’s Use Only

Employer’s

Telephone

Name: ______________________________________________

Number: ( ______ ) ______________ FEIN ____________________

Street Address: ___________________________________________________________________________________________________

City or Town, State, and ZIP Code: ___________________________________________________________________________________

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) .........................................

_______

DATE APPLICANT:

Was

Gave

offered

Was

Started

information

job

hired

job

Under penalties of perjury, I declare that I completed 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 or a long-term family assistance recipient. I hereby request a certification that the individual is a member of a targeted group or

a long-term family assistance recipient.

Employer’s signature >

Title

Date

assistance recipient. This form may also

any Internal Revenue law. Generally, tax

Privacy Act and

be given to the Internal Revenue Service

returns and return information are

Paperwork Reduction

for administration of the Internal Revenue

confidential, as required by section 6103.

laws, to the Department of Justice for civil

Act Notice

The time needed to complete and file

and criminal litigation, to the Department

this form will vary depending on individual

Section references are to the Internal

of Labor for oversight of the certifications

circumstances. The estimated average

Revenue Code.

performed by the SESA, and to cities,

time is:

states, and the District of Columbia for

Recordkeeping .................... 2 hr., 46 min.

Section 51(d)(12) permits a prospective

use in administering their tax laws. In

employer to request the applicant to

Learning about the law

addition, we may disclose this information

complete this form and give it to the

or the form .................................... 36 min.

to Federal, state, or local agencies that

prospective employer. The information will

investigate or respond to acts or threats of

Preparing and sending this

be used by the employer to complete the

terrorism or participate in intelligence or

form to the SESA .......................... 36 min.

employer’s Federal tax return. Completion

counterintelligence activities concerning

If you have comments concerning the

of this form is voluntary and may assist

terrorism.

accuracy of these time estimates or sug-

members of targeted groups and long-

You are not required to provide the

gestions for making this form simpler, we

term family assistance recipients in

information requested on a form that is

would be happy to hear from you. You can

securing employment. Routine uses of

subject to the Paperwork Reduction Act

write to the Tax Forms Committee, West-

this form include giving it to the state

unless the form displays a valid OMB

ern Area Distribution Center, Rancho

employment security agency (SESA),

control number. Books or records relating

Cordova, CA 95743-0001.

which will contact appropriate sources to

to a form or its instructions must be

confirm that the applicant is a member of

DO NOT send this form to this address.

retained as long as their contents may

a targeted group or a long-term family

Instead, see When and Where To File in

become material in the administration of

the separate instructions.

For Michigan new hires, please mail this form to:

Unemployment Insurance Agency

WOTC Unit

P. O. Box 8067

Royal Oak, MI 48068-8067

8850

(Rev. 8-04 Mich. Reprint)

Form

Form 8850 - Pre-Screening Notice And Certification Request For The Work Opportunity And Welfare-To-Work Credits Page 2

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