Form 8850 - Pre-Screening Notice And Certification Request For The Work Opportunity And Welfare-To-Work Credits Page 2
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Form 8850 (Rev. 01-06)
Page
For Employer’s Use Only
(
)
-
Employer’s name
Telephone no.
EIN
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)
Was
Date applicant:
Gave
offered
Was
Started
information
/
/
job
/
/
hired
/
/
job
/
/
Complete Only If Box 1 on Page 1 is Checked
Check if the individual was not my employee
State and
county or
on August 28, 2005 and this is the first time
the employee has been hired by me since
parish of
August 28, 2005.
job
Under penalties of perjury, I declare that the applicant 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
Privacy Act and
The time needed to complete and file
for administration of the Internal
this form will vary depending on
Revenue laws, to the Department of
Paperwork Reduction
individual circumstances. The estimated
Justice for civil and criminal litigation, to
Act Notice
average time is:
the Department of Labor for oversight of
the certifications performed by the
Recordkeeping
5 hrs., 30 min.
Section references are to the Internal
SESA, and to cities, states, and the
Learning about the law
Revenue Code.
District of Columbia for use in
or the form
24 min.
Section 51(d)(12) permits a prospective
administering their tax laws. We may
Preparing and sending this form
employer to request the applicant to
also disclose this information to other
to the SESA
30 min.
complete this form and give it to the
countries under a tax treaty, to federal
If you have comments concerning the
prospective employer. The information
and state agencies to enforce federal
accuracy of these time estimates or
will be used by the employer to
nontax criminal laws, or to federal law
suggestions for making this form
complete the employer’s federal tax
enforcement and intelligence agencies to
simpler, we would be happy to hear
return. Completion of this form is
combat terrorism.
from you. You can write to the Internal
voluntary and may assist members of
You are not required to provide the
Revenue Service, Tax Products
targeted groups and long-term family
information requested on a form that is
Coordinating Committee,
assistance recipients in securing
subject to the Paperwork Reduction Act
SE:W:CAR:MP:T:T:SP, 1111 Constitution
employment. Routine uses of this form
unless the form displays a valid OMB
Ave. NW, IR-6406, Washington, DC
include giving it to the state employment
control number. Books or records
20224.
security agency (SESA), which will
relating to a form or its instructions must
contact appropriate sources to confirm
Do not send this form to this address.
be retained as long as their contents
that the applicant is a member of a
Instead, see When and Where To File in
may become material in the
targeted group or a long-term family
the separate instructions.
administration of any Internal Revenue
assistance recipient. This form may also
law. Generally, tax returns and return
be given to the Internal Revenue Service
information are confidential, as required
by section 6103.
8850
Form
(Rev. 01-06)
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