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information may be required for qualified long-term

hired not more than 1 year after the conviction or release

unemployment recipients.

from prison for that felony.

4. Designated community resident. An individual who

You can get ETA Form 9061 from your local public

is at least age 18 but not yet age 40 on the hiring date and

employment service office or you can download it from the

lives within an empowerment zone or rural renewal county

ETA website at

(defined later).

5. Vocational rehabilitation referral. An individual who

Recordkeeping

has a physical or mental disability resulting in a substantial

handicap to employment and who was referred to the

Keep copies of Forms 8850, any transmittal letters that you

employer upon completion of (or while receiving)

submit to your state WOTC coordinator, and certification

rehabilitation services by a rehabilitation agency approved by

letters you receive from your WOTC coordinator as long as

the state, an employment network under the Ticket to Work

they may be needed for the administration of the provisions

program, or the Department of Veterans Affairs.

relating to the work opportunity credit. Records that support

the credit usually must be kept for 3 years from the date any

6. Summer youth employee. An individual who:

income tax return claiming the credit is due or filed,

Performs services for the employer between May 1 and

whichever is later.

September 15;

Members of Targeted Groups

Is at least age 16 but not yet age 18 on the hiring date (or if

later, on May 1);

A job applicant may be certified as a member of a targeted

Has never worked for the employer before; and

group if he or she is described in one of the following groups.

Lives within an empowerment zone.

1. Qualified IV-A recipient. An individual who is a

7. Recipient of SNAP benefits (food stamps). An

member of a family receiving assistance under a state plan

individual who:

approved under part A of title IV of the Social Security Act

Is at least age 18 but not yet age 40 on the hiring date, and

relating to Temporary Assistance for Needy Families (TANF).

Is a member of a family that:

The assistance must be received for any 9 months during the

a. Has received SNAP benefits for the 6-month period

18-month period ending on the hiring date.

ending on the hiring date; or

2. Qualified veteran. A veteran who is any of the

b. Is no longer eligible for such assistance under section

following.

6(o) of the Food Stamp Act of 1977, but the family received

A member of a family that has received Supplemental

SNAP benefits for at least 3 months of the 5-month period

Nutrition Assistance Program (SNAP) benefits (food stamps)

ending on the hiring date.

for at least a 3-month period during the 15-month period

8. SSI recipient. An individual who is receiving

ending on the hiring date.

supplemental security income benefits under title XVI of the

Unemployed for a period or periods totaling at least 4

Social Security Act (including benefits of the type described

weeks (whether or not consecutive) but less than 6 months in

in section 1616 of the Social Security Act or section 212 of

the 1-year period ending on the hiring date.

Public Law 93-66) for any month ending during the 60-day

Unemployed for a period or periods totaling at least 6

period ending on the hiring date.

months (whether or not consecutive) in the 1-year period

9. Long-term family assistance recipient. An

ending on the hiring date.

individual who is a member of a family that:

Entitled to compensation for a service-connected disability

Has received TANF payments for at least 18 consecutive

and is hired not more than 1 year after being discharged or

months ending on the hiring date; or

released from active duty in the U.S. Armed Forces.

Receives TANF payments for any 18 months (whether or

Entitled to compensation for a service-connected disability

not consecutive) beginning after August 5, 1997, and the

and was unemployed for a period or periods totaling at least

earliest 18-month period beginning after August 5, 1997,

6 months (whether or not consecutive) in the 1-year period

ended during the past 2 years; or

ending on the hiring date.

Stopped being eligible for TANF payments because

Note. Requesting the information in box 4 or box 5 of Form

federal or state law limits the maximum period such

8850 is an exception to the Americans with Disabilities Act's

assistance is payable and the individual is hired not more

prohibition on pre-offer disability-related inquiries. The

than 2 years after such eligibility ended.

purpose of this request is to support the hiring of certain

10. Qualified long-term unemployment recipient. An

disabled veterans, which will entitle the employer to a larger

individual hired after 2015 who on the day before the

work opportunity credit than the hiring of other targeted group

individual begins work for the employer, or, if earlier, the day

members.

the individual completes Form 8850 as a prescreening

To be considered a veteran, the applicant must:

notice, is in a period of unemployment that:

Have served on active duty (not including training) in the

Is not less than 27 consecutive weeks, and

Armed Forces of the United States for more than 180 days or

Includes a period (which may be less than 27 consecutive

have been discharged or released from active duty for a

weeks) in which the individual received unemployment

service-connected disability, and

compensation under state or federal law.

Not have a period of active duty (not including training) of

Member of a Family

more than 90 days that ended during the 60-day period

ending on the hiring date.

With respect to the qualified IV-A recipient, qualified veteran,

3. Qualified ex-felon. An ex-felon who has been

recipient of SNAP benefits (food stamps), and long-term

convicted of a felony under any federal or state law, and is

family assistance recipient, an individual whose family

receives assistance for the requisite period meets the family

-2-

Instructions for Form 8850 (March 2016)

Instructions For Form 8850 - Pre-Screening Notice And Certification Request For The Work Opportunity Credit - 2016 Page 2

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