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Form 8850 - Pre-Screening Notice And Certification Request For The Work Opportunity Credit Page 4

Release Notice

I authorize the Social Security Administration, Department of Social Services, Military

Records, Vocational Rehabilitation, Veterans Administration, Department of Corrections,

Department of Defense, National Guard, California Employment Development Department,

or applicable Indian Tribe to provide the verification of information requested by Ernst &

Young and release of information from those entities as requested. This information will be

used for the sole purpose of determining eligibility, qualification and participation in Federal

and State Tax Credits, including the Work Opportunity Tax Credit Program.

IMPORTANT: Please complete EVERY ITEM below, if applicable.

Name:

Social Security Number:

Name of main recipient (or former recipient),

Who received or is receiving the TANF/AFDC or Food Stamps:

Name of Case Worker/Vocational Counselor/Correctional Officer:

Telephone Number of Case Worker/Vocational Counselor/Correctional Officer:

Agency Name & Address:

Agency City, State, ZIP:

Case Number:

City & County where benefits received:

State where benefits received:

Signature:

Date:

Please mail this form to Ernst & Young at the address on the WOTC Instructions page.

Page 4

Ernst & Young LLP

1201 Main Street, Suite 2000

Phone: (866) 267-5866

Dallas, TX 75202

Attn.: WOTC Processing Center

Form 8850 - Pre-Screening Notice And Certification Request For The Work Opportunity Credit Page 4