Form 85-199 - Texas Enterprise Zone - Post-Employment Employee Certification Survey
Download a blank fillable Form 85-199 - Texas Enterprise Zone - Post-Employment Employee Certification Survey 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 85-199 - Texas Enterprise Zone - Post-Employment Employee Certification Survey 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.
ADVERTISEMENT
1PRINT FORM
CLEAR FORM
85-199
(3-17)
Texas Enterprise Zone – Post-Employment Employee Certification Survey
Texas Comptroller of Public Accounts
The Comptroller of Public Accounts distributes this survey for the Texas Economic Development Council to report the number of jobs we have created and
the economic characteristics of our employees. Completing this survey is voluntary and your responses are confidential.
This survey is used to obtain information from you as an employee of _____________________________________________, located in the
city of ____________________ , Texas.
Employee Name ________________________________________________ Employment Date ___________________________________
Employee Payroll ID#
______________ Home Address, Street,City, Zip Code __________________________________________________
Please check all boxes that apply to you:
I was unemployed for at least three months, from __________ to _________ , before being employed with _______________________________ .
Last employer name _______________________________________ .
I received public assistance benefits before being employed by ________________________________________ , including welfare payments,
Women, Infants and Children (WIC) or food stamps (food stamps must be received by you, not an immediate family member).
List name of public assistance program(s): ___________________________________ Benefit ID#: ______________
I am a low-income individual, as defined by Section 101, Workforce Investment Act of 1998 (29 U.S.C. Section 2801(25)).
I am an individual with a disability as defined by 29 U.S.C. Section 705(20)(A). (Individuals MUST be certified by an authorized agency or doctor.)
Authorized agency name ___________________________ Physician name __________________ Physician phone number _______________
I am an inmate imprisoned by order of a court, whether actually imprisoned in a facility operated by, or under contract with, the Correctional Institutions
Division of the Texas Department of Criminal Justice or under the supervision or custody of that agency’s Paroles Division.
I, or an immediate family member, received Supplemental Security Income (SSI) or Temporary Assistance for Needy Families (TANF) payments.
List the name of the program(s): ______________________________
Program(s) ID#: _____________.
I meet the current low income or moderate income limits (reference below) developed under Section 8, United States Housing Act of 1937 (42 U.S.C.
Section 1437f et seq.) for ______________________ County, Texas.
Enter the year of HUD income level for this certification
_______________________ .
You can access HUD Program Income Limits (Section 8, Section 221(d)(3) BMIR, Section 235 and Section 236) to find the specific income
limits data set to use based on the year employee was hired via this link:
I am a member of a family of _____ whose total family income was (subtotal of the amounts below) $ _____________
before I was hired at or below
the income level indicated from the HUD Program. Income Limits referenced immediately above:
You $ __________
Your spouse $
____________
All dependents $ _____________
Family members living with you $ ____________
Total family income (subtotal of all the amounts above) $ ___________
I was under the permanent managing conservatorship of the Department of Family and Protective Services on the day before my 18th birthday.
I am entering the workforce after being confined in a facility operated by, or under contract with, the Texas Department of Criminal Justice for the
imprisonment of individuals convicted of felonies other than state jail felonies.
I have been released by the Texas Youth Commission and am on parole, if state law provides for such a person to be on parole.
None of the above applies to me.
Certification
I declare and affirm under penalty of perjury that the statements made herein are true and correct to the best of my
knowledge, information and belief.
____________________________
________________
Employee Name Print
Date
____________________________
________________
Employee Signature
Date
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form F-1156z - Florida Enterprise Zone Jobs Credit Certificate Of Eligibility For Corporate Income Tax
Financial
Form Ap-199 - Texas Application For Organizations Engaged Primarily In Performing Charitable Functions And For Corporations That Hold Title To Property For Such Organizations
Financial
Related Categories
Parent category: Financial