Fillable Form 8850 (Rev. August 2009) printable pdf download

TAX CREDIT QUESTIONNAIRE

Form A (rev. 08/12)

EMPLOYER SECTION:

Client:

Company:

Location:

Position:

Starting Wage: $

EMPLOYEE SECTION:

Employee Name:

Street Address:

City/State:

Zip:

SS#:

Date of Birth:

Age:

Have you worked for

If yes, location:

this company before?

_____/_____/________

Yes

Please complete all questions, and sign and date the form.

Yes

1. Have you or has anyone living with you received Temporary Assistance to Needy Families (TANF)

at any time since August 5, 1997?

(If yes, please provide information below.)

Name of the person receiving benefits: ______________________________ Relationship to you: _________________

City: ________________________ County: _____________________ State: ______________

2. Have you or has anyone living with you received Food Stamps (SNAP) at any time during the past 15 months?

(If yes, please provide information below.)

Name of the person receiving benefits: ______________________________ Relationship to you: _________________

City: ________________________ County: _____________________ State: ______________

3. Have you received Supplemental Security Income (SSI) at any time within the past 3 months?

Please note, this is not the same as Social Security benefits (SS) or Social Security Disability (SSDI) benefits.

*If you checked yes please provide a copy of your SSI documentation.

4. Have you received any type of vocational rehabilitation services within the past two years?

If yes, please indicate which type of agency you worked with and provide their location information below:

Vocational Rehabilitation Agency

Dept. of Veterans Affairs

Employment Network (Ticket to Work Program)

Name of Agency: ______________________________ Phone #: ________________________

City: ________________________ County: _____________________ State: ______________

*If you checked yes please provide a copy of your active Individual Work Plan and Ticket to Work documentation

5. Are you a Veteran of the U.S. Military?

*If yes, please provide a copy of your DD-214 and letter of separation.

(If yes, please provide information below. If no, please continue to question #6.)

_____/_____/________

Dates of Service - From:

To:

Branch of Service: ________________________

Are you entitled to or are you receiving compensation for a service-connected disability?

Have you been unemployed at any time during the last 12 months?

_____/_____/________

If yes, dates of unemployment - From:

To:

Did you receive unemployment compensation at any point during your unemployment?

6. Have you been convicted of a felony or released from prison for a felony conviction in the past 12 months?

_____/_____/________

Conviction Date:

Release Date:

Was this a

Federal or

State conviction? If State - County: _______________ State: _______________

Additional Tax Credits

IEC (Native American): Are you or your spouse a member of a Native American Tribe?

*If you checked yes please provide a copy of your CDIB card.

CA Residents:

Are you the child of foster parents?

Do you receive CalWorks?

Workforce Investment Act?

Are you a migrant or seasonal farm worker?

Have you ever been convicted of a misdemeanor?

SC Residents:

Do you receive Family Independence Benefits?

PLEASE READ, SIGN, AND DATE:

Under penalties of perjury, I hereby authorize any agency, organization, Social Security Administration, Department of Veterans Affairs, or

necessary individuals to supply such verification or information as may be needed to determine tax credit eligibility to my employer, employer

representative Associated Consultants, Inc. dba Retrotax, or the Department of Labor.

New Employee Signature: ____________________________________________________ Date: _____________________________

Form 8850 (Rev. August 2009)

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