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

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8850

Pre-Screening Notice and Certification Request for

Form

the Work Opportunity and Welfare-to-Work Credits

OMB No. 1545-1500

(Rev. January 2006)

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

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

Work Opportunity Credit

Check here if you are a Hurricane Katrina employee. Enter the address of your main home on August 28, 2005, and the

state and county or parish in which it was located.

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, an employment network under the Ticket to Work

program, 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 maximum

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. 01-06)