Sodexo Texas Unit Hire Wotc Forms Instructions Page 4
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4Release Notice
________________________________
COMPANY NAME
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I hereby authorize the Department of Social Services, Social Security Administration for Supplemental Security Income, Military Records,
Vocational Rehabilitation, Department of Defense, National Guard, Department of Motor Vehicles, Veterans Administration, Superior Court of
California, California Employment Development Department, Tribal Governments, Department of Corrections or Probation and/or Parole to
provide the verification of information requested by Ernst & Young or State Workforce Agencies (SWA) and release of information to those
entities as requested. This information will be used for the sole purpose of determining my eligibility, qualification and participation in Federal and
State Tax Credits, including the Work Opportunity Tax Credit Program.
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 and Address
Agency City, State, Zip
Case Number
City & County Where Benefits Received
State Where Benefits Received
Marital Status
Single
Married
If single, will you be claimed on your parent’s tax return this year?
Yes
No
How many family members (include yourself, spouse and dependent children only) are living in household
Other than yourself, did any family members have income 3 months prior
at time of hire?
to your hire?
Yes
No
Most Recent Employer Company Name:
Last Day Worked:
Reason for Leaving
/
/
Signature
Date
Mail or Fax to Ernst & Young
WOTC Processing Center
P.O. Box 226896
Dallas, TX 75222
Fax: 1 (800) 929-0989
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The W-4 form below is used for documentation purposes for the Work Opportunity Tax Credit program only. Completing this W-4 will
not affect your job, wages or taxes. Thank you for your participation.
Date of Birth:
/
/
Mail or Fax to Ernst & Young
WOTC Processing Center
P.O. Box 226896
Dallas, TX 75222
Fax: 1 (800) 929-0989
308
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