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Panel 609
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Form 8850
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Panel 25
(n)
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Form: 8850
(Rev. January 31, 2020)
Department of the Treasury
Internal Revenue Service
(n)
Panel 26
(n)
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Pre-Screening Notice and Certification Request for
the Work Opportunity Credit
(n)
Panel 24
(n)
OMB No. 1545-1500
(n)
Job applicant: Fill in the lines below and check any boxes that apply.
(n)
Instructions :
1. Please fill all the mandatory fields marked with
*
.
2. Mandatory fields not filled or incorrectly filled will be highlighted in red for your information.
3. This online form can only be used to fill in application for SNAP, TANF, LTFAR and LTU target categories only.
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x
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Your First Name
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Panel 548
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Middle Initial
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Panel 35
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Last Name
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Social Security Number(enter 9 digits, no dashes)
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Panel 40
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Street address where you live
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Applicant Street Address2
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Panel 554
(n)
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City or Town (Select 'Other' if out of State)
*
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Abingdon
Addieville
Addison
Adeline
Albany
Albers
Albion
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Alexis
Algonquin
Alhambra
Allendale
Allenville
Allerton
Alma
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Alpha
Alsey
Alsip
Altamont
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Altona
Alvin
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Anchor
Andalusia
Andover
Anna
Annawan
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AppleRiver
Arcola
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Arlington Heights
Armington
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Arthur
Ashkum
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Ashley
Ashmore
Ashton
Assumption
Astoria
Athens
Atkinson
Atlanta
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Augusta
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Avon
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Barry
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Bartlett
Bartonville
Basco
Batavia
Batchtown
Bath
BayView Gardens
Baylis
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Beardstown
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Beckemeyer
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Beecher
Beecher City
Belgium
Belknap
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Bowen
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Bradley
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Bryant
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Buda
Buffalo
Buffalo Grove
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Bulpitt
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Burlington
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Burnt Prairie
BurrRidge
Bush
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Butler
Byron
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Cairo
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Calumet Park
Camargo
Cambria
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Camden
CampPoint
Campbell Hill
Campus
Canton
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Capron
Carbon Cliff
Carbon Hill
Carbondale
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Carlock
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Carrier Mills
Carrollton
Carterville
Carthage
Cary
Casey
Caseyville
Catlin
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Cedarville
CentralCity
Centralia
Centreville
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Chadwick
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Chapin
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Chenoa
Cherry
Cherry Valley
Chester
Chesterfield
Chicago
Chicago Heights
Chicago Ridge
Chillicothe
Chrisman
Christopher
Cicero
Cisco
Cisne
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Claremont
Clarendon Hills
ClayCity
Clayton
Clear Lake
Cleve land
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Clinton
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Coal Valley
Coalton
Coatsburg
Cobden
Coffeen
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Coleta
Colfax
Collinsville
Collinville
Colona
Colp
Columbia
Columbus
Compton
Concord
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Cooksville
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Cornell
Cortland
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Country Club Hills
Countryside
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Creston
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Crete
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Crossville
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Cuba
Cullom
Curran
Cutler
Cypress
Dahlgren
Dakota
Dallas City
Dalton City
Dalzell
Damiansville
Dana
Danforth
Danvers
Danville
Darien
Davis
Davis Junction
Dawson
DeLand
DePue
DeSoto
Decatur
Deer Creek
Deer Grove
Deer Park
Deer field
Dekalb
Delavan
Des Plaines
Desoto
Detroit
Dewitt
Diamond
Dieterich
Divernon
Dix
Dixmoor
Dixon
Dolton
Dongola
Donnellson
Donovan
Dorchester
Dover
Dowell
Downers Grove
Downs
DuBois
DuQuoin
Dunferm line
Dunlap
Dupo
Duquoin
Durand
Dwight
EStLouis
Eagarville
Earlville
EastAlton
East Brooklyn
East Cape Girardeau
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East HazelCrest
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Easton
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Edgewood
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ElPaso
Elburn
Eldorado
Eldred
Elgin
Elizabeth
Elizabeth town
ElkGrove Village
Elkhart
Elkhorn
Elkville
Elliott
EllisGrove
Ellisville
Ellsworth
Elmhurst
Elmwood Park
Elsah
Elvaston
Elwood
Emden
Emington
Energy
Enfield
Equality
Erie
Essex
Eureka
Evanston
Evansville
Evergreen Park
Ewing
Exeter
Fairbury
Fairfield
Fairmont City
Fairmount
Fairview
Fairview Heights
Farina
Farmer City
Farmersville
Farmington
Fayetteville
Fenton
Ferris
Fidelity
Fieldon
Fillmore
Findlay
Fisher
Fithian
Flanagan
FlatRock
Flora
Florence
Flossmoor
Foosland
Ford Heights
Forest City
Forest Park
Forest View
Forrest
Forreston
Forsyth
Fort Collins
FoxLake
Fox River Grove
Fox River Valley Gardens
Frankfort
Franklin
Franklin Grove
Franklin Park
Frankport
Freeburg
Freeman Spur
Freeport
Fulton
Fults
Galatia
Galena
Galesburg
Galva
Garden Prairie
Gardner
Garrett
Gays
Geneseo
Geneva
Genoa
Genoa City
Georgetown
German Valley
German town
German town Hills
Gibson City
Gifford
Gilberts
Gillespie
Gilman
Gilson
Girard
Gladstone
Glasford
Glasgow
Glen Carbon
Glen Ellyn
Glencoe
Glendale Heights
GlendaleHts
Glenview
Glenwood
Godfrey
Godley
Golconda
Golden
GoldenGate
Golf
Good Hope
Goodfield
Goreville
Gorham
Grafton
Grand Ridge
Grand Tower
Grandview
Granite City
Grant Park
Grant fork
Granville
Grays lake
Grayville
Green Oaks
Green Valley
Greenfield
Greensboro
Greenup
Greenview
Greenville
Greenwood
Gridley
Griggsville
GulfPort
Gurnee
Hainesville
Hamburg
Hamel
Hamilton
Hammond
Hampshire
Hampton
Hanaford
HannaCity
Hanover
Hanover Park
Hardin
Harmon
Harrisburg
Harristown
Hartford
Hartsburg
Harvard
Harvel
Harvey
Harwood Heights
Havana
Hawthorn Woods
HazelCrest
Hazelwood
Hebron
Hecker
Henderson
Hennepin
Henning
Henry
Hernin
Herrick
Herrin
Herscher
Hettick
Heyworth
Hickory Hills
Hidalgo
Highland
Highland Park
Highwood
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Hillsdale
Hillside
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Hinckley
Hindsboro
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Hoffman Estates
Holiday Hills
Holloway ville
Homer
HomerGlen
Hometown
Homewood
Hoopeston
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Hoyleton
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Huey
Hull
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Hume
Huntley
Hurst
Hutsonville
Illiopolis
Ina
Indian Creek
Indian HeadPark
Indianapolis
Indianola
Industry
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Ipava
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Irvington
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Justice
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Kings
Kingston
Kingston Mines
Kinmundy
Kinsman
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Kirkwood
Knoxville
LaFayette
LaGrange
LaGrange Park
La Harpe
La Moille
La Prairie
La Rose
La Salle
Lacon
Ladd
Lafayette
Lake Barrington
Lake Bluff
Lake Forest
Lake In The Hills
LakeKa-ho
LakeVilla
Lake Zurich
Lakemoor
Lakewood
Lanark
Lansing
LasVegas
Lasalle
Latham
Lawrenceville
LeRoy
LeafRiver
Lebanon
Lee
Leland
Leland Grove
Lemont
Lena
Lenzburg
Leonore
Lerna
Lewistown
Lexington
Liberty
Libertyville
LilyLake
Lima
Limestone
Lincoln
Lincolnshire
Lincolnwood
Lindenhurst
Lisbon
Lisle
Litchfield
LittleYork
Littleton
Liverpool
Livingston
Loami
Lockport
Loda
Lomax
Lombard
LondonMills
Long Creek
Long Grove
LongPoint
Longview
Loraine
Lostant
Louisville
LovesPark
Lovington
Ludlow
Lyndon
Lynnville
Lynwood
Lyons
Macedonia
Machesney Park
Mackinaw
Macomb
Macon
Madison
Maeystown
Magnolia
Mahomet
Makanda
Malden
Malta
Manchester
Manhattan
Manito
Manlius
Mansfield
Manteno
MaplePark
Mapleton
Maquon
Marengo
Marietta
Marine
Marion
Marissa
Mark
Markham
Maroa
Marquette Heights
Marseilles
Marshall
Martinsville
Martinton
Maryville
Mascoutah
MasonCity
Matherville
Matoon
Matteson
Mattoon
Maunie
Mayfield
Maywood
Mazon
Mcclure
Mccook
Mccullom Lake
Mchenry
Mclean
Mcleansboro
Mcnabb
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Media
Medora
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Melvin
Mendon
Mendota
Menominee
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Mesa
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Metcalf
Metropolis
Mettawa
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Midlothian
Milan
Milford
MillCreek
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Milton
Mineral
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Modesto
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Monee
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Monroe
Monroe Center
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Montrose
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Morrison
Morrisonville
Morton
Morton Grove
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Mounds
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Normal
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Norwood
OakBrook
OakCreek
OakForest
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OakLawn
OakPark
Oakbrook Terrace
Oakdale
Oakford
Oakland
Oakley
Oakpark
Oakwood
Oakwood Hills
Oblong
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Odell
Odin
Ofallon
O'fallon
Ogden
Oglesby
Ohio
Ohlman
Okawville
Old Mill Creek
Old Ripley
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Olmsted
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Olympia Fields
Omaha
Onarga
Oneida
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Orangeville
Oreana
Oregon
Orient
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Palmer
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Pana
Panama
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Paris
Park City
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ParkRidge
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Pearl City
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Peoria
Peoria Heights
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Peru
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Philo
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Pingree Grove
Piper City
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Plainfield
Plainville
Plano
Plattville
Pleasant Hill
Pleasant Plains
Pleasant Prairie
Plymouth
Pocahontas
Polo
Pontiac
Pontoon Beach
Pontoosuc
Poplar Grove
Port Byron
Posen
Potomac
Prairie City
Prairie DuRocher
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Princeton
Princeville
Prophetstown
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Pulaski
Quincy
Radom
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Rankin
Ransom
Rantoul
Rapids City
Raritan
Raymond
RedBud
Reddick
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Richmond
Richton Park
Richview
RidgeFarm
Ridgway
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Ringwood
Rio
Ripley
River Forest
River Grove
Riverdale
Riverside
Riverton
Riverwoods
Roanoke
Robbins
Roberts
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Rochester
Rock City
Rock Falls
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Rockwood
Rolling Meadows
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Roscoe
Rose Hill
Roselle
Rosemont
Roseville
Rosiclare
Rossville
RoundLake
Round Lake Beach
Round Lake Heights
Round Lake Park
Roxana
Royal
Royal Lakes
Royalton
Ruma
Rushville
Russellville
Rutland
Sadorus
Sailor Springs
Salem
Sammons Point
SanJose
Sandoval
Sandwich
Sauget
Sauk Village
Saunemin
Savanna
Savoy
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Saybrook
Scales Mound
Schaumburg
Schiller Park
Schram City
Sciota
Scottville
Seaton
Seatonville
Secor
Seneca
Serena
Sesser
Shabbona
Shannon
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Sheridan
Sherman
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Shiloh
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Shumway
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Silvis
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Sims
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SoBeloit
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South Elgin
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Southern View
Sparland
Sparta
Spaulding
Spillertown
SpringBay
SpringGrove
Spring Valley
Springerton
Springfield
St John
StLouis
St.Anne
St.Augustine
St.Charles
St.David
St.Elmo
St.Francisville
St.Jacob
St.Johns
St.Joseph
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Standard
Standard City
Stanford
Staunton
Ste.Marie
Steeleville
Steger
Sterling
Steward
Stewardson
Stickney
Stillman Valley
Stockton
StonePark
Stonefort
Stonington
Stoy
Strasburg
Strawn
Streamwood
Streator
Stronghurst
Sublette
Sugar Grove
Sullivan
Summerfield
Summit
Sumner
Sun River Terrace
Sutter
Swansea
Sycamore
Symerton
Table Grove
Tallula
Tamaroa
Tamms
Tampico
Taylor Springs
Tennessee
Teutopolis
Thawville
Thayer
Thebes
Third Lake
Thomasboro
Thompsonville
Thomson
Thornton
Tilden
Tilton
Timberlane
Time
TinleyPark
Tiskilwa
Toledo
Tolono
Toluca
Tonica
Topeka
Tovey
Towanda
Tower Hill
Tower Lakes
Tremont
Trenton
Trevor
Trout Valley
Troy
Troy Grove
Tuscola
Twin Lakes
Ullin
Union
Union City
Union Hill
University Park
Urbana
Ursa
Utica
Valier
Valley City
Valmeyer
Vandalia
Varna
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Venice
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Vermilion
Vermont
Vernon
Vernon Hills
Verona
Versailles
Victoria
Vienna
Villa Grove
Villa Park
Viola
Virden
Virgil
Virginia
Volo
Wadsworth
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Walnut
Walnut Hill
Walshville
Waltonville
Wamac
Wapella
Warren
Warrensburg
Warrenville
Warsaw
Washburn
Washington
Washington Park
Wataga
Waterloo
Waterman
Watseka
Watson
Wauconda
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Wayne
Wayne City
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Wenona
Wenonah
West Brooklyn
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Western Springs
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Westmont
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Wheaton
Wheeler
Wheeling
White City
White Hall
Whiteash
Williamsfield
Williamson
Williamsville
Willisville
Willow Hill
Willow Springs
Willowbrook
Wilmette
Wilmington(GreeneCounty)
Wilmington(WillCounty)
Wilsonville
Winchester
Windsor
Windsor(ShelbyCounty)
Winfield
Winnebago
Winnetka
Winslow
Winthrop Harbor
Witt
WolfLake
WonderLake
WoodDale
WoodRiver
Woodhull
Woodland
Woodlawn
Woodridge
Woodson
Woodstock
Worden
Worth
Wyanet
Wyoming
Xenia
Yale
Yates City
Yorkville
Zeigler
Zion
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Other
(n)
Panel 553
(n)
Drag and drop controls from the palette or from the form.
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-
State
*
x
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
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Maryland
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Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
(n)
Panel 552
(n)
Drag and drop controls from the palette or from the form.
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-
Zip Code
*
x
(n)
Invalid City , Please Select a Valid City
(n)
+
-
Specify the City
*
x
(n)
Panel 45
(n)
Drag and drop controls from the palette or from the form.
+
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County (Select 'Other' if out of State)
*
x
ADAMS
ALEXANDER
BOND
BOONE
BROWN
BUREAU
CALHOUN
CARROLL
CASS
CHAMPAIGN
CHRISTIAN
CLARK
CLAY
CLINTON
COLES
COOK
CRAWFORD
CUMBERLAND
DEKALB
DEWITT
DOUGLAS
DUPAGE
EDGAR
EDWARDS
EFFINGHAM
FAYETTE
FORD
FRANKLIN
FULTON
GALLATIN
GREENE
GRUNDY
HAMILTON
HANCOCK
HARDIN
HENDERSON
HENRY
IROQUOIS
JACKSON
JASPER
JEFFERSON
JERSEY
JO DAVIESS
JOHNSON
KANE
KANKAKEE
KENDALL
KNOX
LAKE
LASALLE
LAWRENCE
LEE
LIVINGSTON
LOGAN
MCDONOUGH
MCHENRY
MCLEAN
MACON
MACOUPIN
MADISON
MARION
MARSHALL
MASON
MASSAC
MENARD
MERCER
MONROE
MONTGOMERY
MORGAN
MOULTRIE
OGLE
PEORIA
PERRY
PIATT
PIKE
POPE
PULASKI
PUTNAM
RANDOLPH
RICHLAND
ROCK ISLAND
ST.CLAIR
SALINE
SANGAMON
SCHUYLER
SCOTT
SHELBY
STARK
STEPHENSON
TAZEWELL
UNION
VERMILION
WABASH
WARREN
WASHINGTON
WAYNE
WHITE
WHITESIDE
WILL
WILLIAMSON
WINNEBAGO
WOODFORD
STWDE/UNCLAS
----------
Other
(n)
Invalid County , Please Select a Valid County
(n)
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Specify the County
*
x
(n)
Panel 711
(n)
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Telephone Number
Enter as:
###-###-####
###.###.####
###-#### or
###.####
(n)
Panel 44
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Email Address
*
x
(n)
Panel 50
(n)
Drag and drop controls from the palette or from the form.
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If you are under age 40, enter your date of birth (mm/dd/yyyy)
*
x
(n)
+
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*
x
Check here if you received a conditional certification from the state workforce agency (SWA) or a participating local agencyfor the work opportunity credit.
(n)
+
-
Checkbox 54
*
x
Check here if any of the following statements apply to you.
(n)
I am a member of a family that has received assistance from Temporary Assistance for Needy Families (TANF) for any 9 months during the past 18 months
I am a veteran and a member of a family that received Supplemental Nutrition Assistance Program (SNAP) benefits (food stamps) for at least a 3-month period during the past 15 months.
I was referred here by a rehabilitation agency approved by the state, an employment network under the Ticket to Work program, or the Department of Veterans Affairs
I am at least age 18 but not age 40 or older and I am a member of a family that:
a.
Received SNAP benefits (food stamps) for the past 6 months, or
b.
Received SNAP benefits (food stamps) for at least 3 of the past 5 months, but is no longer eligible to receive them.
During the past year, I was convicted of a felony or released from prison for a felony.
I received supplemental security income (SSI) benefits for any month ending during the past 60 days.
I am a veteran and I was unemployed for a period or periods totaling at least 4 weeks but less than 6 months during the past year.
(n)
+
-
Checkbox 55
*
x
Check here if you are a veteran and you were unemployed for a period or periods totaling at least 6 months during the past year.
(n)
+
-
Checkbox 926
*
x
Check here if you are a veteran entitled to compensation for a service-connected disability and you were released from active duty in the US.Armed Forces during the past year.
(n)
+
-
Checkbox 927
*
x
Check here if you are a veteran entitled to compensation for a service-connected disability and you were unemployed for a period or periods totaling at least 6 months during the past year.
(n)
+
-
Checkbox 56
*
x
Check here if you are a member of a family that:
(n)
Received TANF payments for at least the past 18 months, or
Received TANF payments for any 18 months beginning after August 5, 1997, and the earliest 18-month period beginning after August 5, 1997, ended during the past 2 years, or
Stopped being eligible for TANF payments during the past 2 years because federal or state law limited the maximum time those payments could be made.
(n)
+
-
Checkbox 930
*
x
Check here if you are in a period of unemployment that is at least 27 consecutive weeks and for all or part of that period you received unemployment compensation.
(n)
Signature---All Applicants Must Sign
(n)
Under penalties of perjury, I declare that I gave the above information to the employer on or before the day I was offered a job, and it is, to the best of my knowledge, true, correct, and complete.
(n)
Panel 61
(n)
Drag and drop controls from the palette or from the form.
+
-
Job applicant's signature
*
x
Select check-box in lieu of your signature
(n)
Panel 60
(n)
Drag and drop controls from the palette or from the form.
+
-
Date
*
x
(n)
For Employer's Use Only
(n)
Panel 75
(n)
Drag and drop controls from the palette or from the form.
+
-
Employer's Name
*
x
(n)
Panel 76
(n)
Drag and drop controls from the palette or from the form.
+
-
Telephone Number
*
Enter as:
###-###-####
###.###.####
###-#### or
###.####
(n)
Panel 77
(n)
Drag and drop controls from the palette or from the form.
+
-
EIN(enter 9 digits,no dashes)
*
Enter as:
#########
(n)
Panel 78
(n)
Drag and drop controls from the palette or from the form.
+
-
Street Address
*
x
(n)
Panel 554
(n)
Drag and drop controls from the palette or from the form.
+
-
City or Town (Select 'Other' if out of State)
*
x
Abingdon
Addieville
Addison
Adeline
Albany
Albers
Albion
Aledo
Alexis
Algonquin
Alhambra
Allendale
Allenville
Allerton
Alma
Alorton
Alpha
Alsey
Alsip
Altamont
AltoPass
Alton
Altona
Alvin
Amboy
Anchor
Andalusia
Andover
Anna
Annawan
Antioch
AppleRiver
Arcola
Arenzville
Argenta
Arlington
Arlington Heights
Armington
AromaPark
Arrowsmith
Arthur
Ashkum
Ashland
Ashley
Ashmore
Ashton
Assumption
Astoria
Athens
Atkinson
Atlanta
Atwood
Auburn
Augusta
Aurora
Ava
Aviston
Avon
Baldwin
Banner
Bannockburn
Bardolph
Barrington
Barrington Hills
Barry
Bartelson
Bartlett
Bartonville
Basco
Batavia
Batchtown
Bath
BayView Gardens
Baylis
BeachPark
Beardstown
Beaverville
Beckemeyer
BedfordPark
Beecher
Beecher City
Belgium
Belknap
BellePrairie City
BelleRive
Belleville
Bellevue
Bellflower
Bellmont
Bellwood
Beloit
Belvidere
Bement
Benld
Bensenville
Benson
Benton
Berkeley
Berlin
Berwyn
Bethalto
Bethany
BigRock
Biggsville
Bingham
Birds
BishopHill
Bismarck
Blandinsville
Bloomingdale
Bloomington
Blue Island
Blue Mound
Bluffs
Bluford
Bolingbrook
Bondville
BoneGap
Bonfield
Bonnie
Bourbonnais
Bowen
Braceville
Bradford
Bradley
Braidwood
Breese
Bridgeport
Bridgeton
Bridgeview
Brighton
Brimfield
Broadlands
Broadview
Broadwell
Brocton
Brookfield
Brooklyn
Brookport
Broughton
Browning
Browns
Brownstown
Brussels
Bryant
Buckingham
Buckley
Buckner
Buda
Buffalo
Buffalo Grove
BullValley
Bulpitt
Buncombe
Bunker Hill
Burbank
Bureau Junction
Burlington
Burnham
Burnt Prairie
BurrRidge
Bush
Bushnell
Butler
Byron
Cabery
Cahokia
Cairo
Caledonia
Calhoun
Calumet City
Calumet Park
Camargo
Cambria
Cambridge
Camden
CampPoint
Campbell Hill
Campus
Canton
Cantrall
Cape Girardeau
Capron
Carbon Cliff
Carbon Hill
Carbondale
Carlinville
Carlock
Carlyle
Carmi
Carol Stream
Carpentersville
Carrier Mills
Carrollton
Carterville
Carthage
Cary
Casey
Caseyville
Catlin
Cave-in-rock
CedarPoint
Cedarville
CentralCity
Centralia
Centreville
CerroGordo
Chadwick
Chambersburg
Champaign
Chandlerville
Channahon
Chapin
Charleston
Chatham
Chattanooga
Chebanse
Chenoa
Cherry
Cherry Valley
Chester
Chesterfield
Chicago
Chicago Heights
Chicago Ridge
Chillicothe
Chrisman
Christopher
Cicero
Cisco
Cisne
Cissna Park
Claremont
Clarendon Hills
ClayCity
Clayton
Clear Lake
Cleve land
Clifton
Clinton
Coal City
Coal Valley
Coalton
Coatsburg
Cobden
Coffeen
Colchester
Coleta
Colfax
Collinsville
Collinville
Colona
Colp
Columbia
Columbus
Compton
Concord
Congerville
Cooksville
Cordova
Cornell
Cortland
Coulterville
Country Club Hills
Countryside
Covington
Cowden
Crainville
Creal Springs
Crescent City
CrestHill
Creston
Crestwood
Crete
CreveCoeur
Crossville
Crystal Lake
Cuba
Cullom
Curran
Cutler
Cypress
Dahlgren
Dakota
Dallas City
Dalton City
Dalzell
Damiansville
Dana
Danforth
Danvers
Danville
Darien
Davis
Davis Junction
Dawson
DeLand
DePue
DeSoto
Decatur
Deer Creek
Deer Grove
Deer Park
Deer field
Dekalb
Delavan
Des Plaines
Desoto
Detroit
Dewitt
Diamond
Dieterich
Divernon
Dix
Dixmoor
Dixon
Dolton
Dongola
Donnellson
Donovan
Dorchester
Dover
Dowell
Downers Grove
Downs
DuBois
DuQuoin
Dunferm line
Dunlap
Dupo
Duquoin
Durand
Dwight
EStLouis
Eagarville
Earlville
EastAlton
East Brooklyn
East Cape Girardeau
East Carondelet
East Dubuque
East Dundee
East Galesburg
East Gillespie
East HazelCrest
East Moline
East Peoria
East St.Louis
Easton
Eddyville
Edgewood
Edinburg
Edwardsville
Effingham
ElDara
ElPaso
Elburn
Eldorado
Eldred
Elgin
Elizabeth
Elizabeth town
ElkGrove Village
Elkhart
Elkhorn
Elkville
Elliott
EllisGrove
Ellisville
Ellsworth
Elmhurst
Elmwood Park
Elsah
Elvaston
Elwood
Emden
Emington
Energy
Enfield
Equality
Erie
Essex
Eureka
Evanston
Evansville
Evergreen Park
Ewing
Exeter
Fairbury
Fairfield
Fairmont City
Fairmount
Fairview
Fairview Heights
Farina
Farmer City
Farmersville
Farmington
Fayetteville
Fenton
Ferris
Fidelity
Fieldon
Fillmore
Findlay
Fisher
Fithian
Flanagan
FlatRock
Flora
Florence
Flossmoor
Foosland
Ford Heights
Forest City
Forest Park
Forest View
Forrest
Forreston
Forsyth
Fort Collins
FoxLake
Fox River Grove
Fox River Valley Gardens
Frankfort
Franklin
Franklin Grove
Franklin Park
Frankport
Freeburg
Freeman Spur
Freeport
Fulton
Fults
Galatia
Galena
Galesburg
Galva
Garden Prairie
Gardner
Garrett
Gays
Geneseo
Geneva
Genoa
Genoa City
Georgetown
German Valley
German town
German town Hills
Gibson City
Gifford
Gilberts
Gillespie
Gilman
Gilson
Girard
Gladstone
Glasford
Glasgow
Glen Carbon
Glen Ellyn
Glencoe
Glendale Heights
GlendaleHts
Glenview
Glenwood
Godfrey
Godley
Golconda
Golden
GoldenGate
Golf
Good Hope
Goodfield
Goreville
Gorham
Grafton
Grand Ridge
Grand Tower
Grandview
Granite City
Grant Park
Grant fork
Granville
Grays lake
Grayville
Green Oaks
Green Valley
Greenfield
Greensboro
Greenup
Greenview
Greenville
Greenwood
Gridley
Griggsville
GulfPort
Gurnee
Hainesville
Hamburg
Hamel
Hamilton
Hammond
Hampshire
Hampton
Hanaford
HannaCity
Hanover
Hanover Park
Hardin
Harmon
Harrisburg
Harristown
Hartford
Hartsburg
Harvard
Harvel
Harvey
Harwood Heights
Havana
Hawthorn Woods
HazelCrest
Hazelwood
Hebron
Hecker
Henderson
Hennepin
Henning
Henry
Hernin
Herrick
Herrin
Herscher
Hettick
Heyworth
Hickory Hills
Hidalgo
Highland
Highland Park
Highwood
Hillcrest
Hillsboro
Hillsdale
Hillside
Hillview
Hinckley
Hindsboro
Hinsdale
Hodgkins
Hoffman
Hoffman Estates
Holiday Hills
Holloway ville
Homer
HomerGlen
Hometown
Homewood
Hoopeston
Hooppole
Hopedale
Hopewell
Hopkins Park
Hoyleton
Hudson
Huey
Hull
Humboldt
Hume
Huntley
Hurst
Hutsonville
Illiopolis
Ina
Indian Creek
Indian HeadPark
Indianapolis
Indianola
Industry
Ingleside
Inverness
Iola
Ipava
Iroquois
Irving
Irvington
Irwin
IslandLake
Itasca
Iuka
Ivesdale
Jacksonville
Janesville
Jeffersonville
Jeisyville
Jerome
Jerseyville
Jewett
Johnsburg
Johnsonville
Johnston City
Joliet
Joppa
Joy
Junction
Junction City
Justice
Kampsville
Kane
Kaneville
Kangley
Kankakee
Kansas
Kappa
Karnak
Kaskaskia
Keenes
Keensburg
Keithsburg
Kell
Kempton
Kenilworth
Kenney
Kenosha
Kewanee
Keyesport
Kilbourne
Kildeer
Kincaid
Kinder hook
Kings
Kingston
Kingston Mines
Kinmundy
Kinsman
Kirkland
Kirkwood
Knoxville
LaFayette
LaGrange
LaGrange Park
La Harpe
La Moille
La Prairie
La Rose
La Salle
Lacon
Ladd
Lafayette
Lake Barrington
Lake Bluff
Lake Forest
Lake In The Hills
LakeKa-ho
LakeVilla
Lake Zurich
Lakemoor
Lakewood
Lanark
Lansing
LasVegas
Lasalle
Latham
Lawrenceville
LeRoy
LeafRiver
Lebanon
Lee
Leland
Leland Grove
Lemont
Lena
Lenzburg
Leonore
Lerna
Lewistown
Lexington
Liberty
Libertyville
LilyLake
Lima
Limestone
Lincoln
Lincolnshire
Lincolnwood
Lindenhurst
Lisbon
Lisle
Litchfield
LittleYork
Littleton
Liverpool
Livingston
Loami
Lockport
Loda
Lomax
Lombard
LondonMills
Long Creek
Long Grove
LongPoint
Longview
Loraine
Lostant
Louisville
LovesPark
Lovington
Ludlow
Lyndon
Lynnville
Lynwood
Lyons
Macedonia
Machesney Park
Mackinaw
Macomb
Macon
Madison
Maeystown
Magnolia
Mahomet
Makanda
Malden
Malta
Manchester
Manhattan
Manito
Manlius
Mansfield
Manteno
MaplePark
Mapleton
Maquon
Marengo
Marietta
Marine
Marion
Marissa
Mark
Markham
Maroa
Marquette Heights
Marseilles
Marshall
Martinsville
Martinton
Maryville
Mascoutah
MasonCity
Matherville
Matoon
Matteson
Mattoon
Maunie
Mayfield
Maywood
Mazon
Mcclure
Mccook
Mccullom Lake
Mchenry
Mclean
Mcleansboro
Mcnabb
Mechanicsburg
Media
Medora
Melrose Park
Melvin
Mendon
Mendota
Menominee
Meredosia
Merrionette Park
Mesa
Metamora
Metcalf
Metropolis
Mettawa
Middletown
Midlothian
Milan
Milford
MillCreek
MillShoals
Millbrook
Milledgeville
Millington
Millstadt
Milton
Mineral
Minier
Minonk
Minooka
Modesto
Mokena
Moline
Momence
Monee
Monmouth
Monroe
Monroe Center
Montgomery
Monticello
Montrose
Morris
Morrison
Morrisonville
Morton
Morton Grove
MoundCity
Mound Station
Mounds
Mount Auburn
Mount Carmel
Mount Carroll
Mount Clare
Mount Erie
Mount Morris
Mount Olive
Mount Prospect
Mount Pulaski
Mount Sterling
Mount Vernon
Mount Zion
Moweaqua
MtCarmel
MtSterling
MtVernon
Mt.Carmel
Muddy
Mulberry Grove
Mulkey town
Muncie
Mundelein
Murphysboro
Murrayville
Naperville
Naplate
Nashville
Nason
Nauvoo
Nebo
Nelson
Neoga
Neponset
New Athens
New Baden
New Bedford
New Berlin
New Boston
New Burnside
New Douglas
New GrandChain
New Haven
New Holland
New Lenox
New Milford
New Minden
New Salem
Newark
Newman
Newton
Niantic
Niles
Noble
Nokomis
Nora
Normal
Norridge
Norris
Norris City
North Aurora
North Barrington
North Chicago
North City
North Henderson
North Pekin
North Riverside
North Utica
North brook
North field
North lake
Norwood
OakBrook
OakCreek
OakForest
OakGrove
OakLawn
OakPark
Oakbrook Terrace
Oakdale
Oakford
Oakland
Oakley
Oakpark
Oakwood
Oakwood Hills
Oblong
Oconee
Odell
Odin
Ofallon
O'fallon
Ogden
Oglesby
Ohio
Ohlman
Okawville
Old Mill Creek
Old Ripley
Old Shawneetown
Olmsted
Olney
Olympia Fields
Omaha
Onarga
Oneida
Oquawka
Orangeville
Oreana
Oregon
Orient
Orion
Orland Hills
Orland Park
Oswego
Ottawa
Owaneco
Paducah
Palatine
Palestine
Palmer
Palmyra
Palos Heights
Palos Hills
Palos Park
Pana
Panama
Panola
Papineau
Paris
Park City
Park Forest
ParkRidge
Parkersburg
Patoka
PawPaw
Pawnee
Paxton
Payson
Pearl
Pearl City
Pecatonica
Pekin
Pell Lake
Peoria
Peoria Heights
Peotone
Percy
Perry
Peru
Pesotum
Petersburg
Phillipstown
Philo
Phoenix
Pierron
Pinckneyville
Pingree Grove
Piper City
Pittsburg
Pittsfield
Plainfield
Plainville
Plano
Plattville
Pleasant Hill
Pleasant Plains
Pleasant Prairie
Plymouth
Pocahontas
Polo
Pontiac
Pontoon Beach
Pontoosuc
Poplar Grove
Port Byron
Posen
Potomac
Prairie City
Prairie DuRocher
Prairie Grove
Princeton
Princeville
Prophetstown
Prospect Heights
Pulaski
Quincy
Radom
Raleigh
Ramsey
Rankin
Ransom
Rantoul
Rapids City
Raritan
Raymond
RedBud
Reddick
Redmon
Reynolds
Richmond
Richton Park
Richview
RidgeFarm
Ridgway
Ridott
Ringwood
Rio
Ripley
River Forest
River Grove
Riverdale
Riverside
Riverton
Riverwoods
Roanoke
Robbins
Roberts
Robinson
Rochelle
Rochester
Rock City
Rock Falls
Rock Island
Rockbridge
Rockdale
Rockford
Rockton
Rockwood
Rolling Meadows
Romeoville
Roodhouse
Roscoe
Rose Hill
Roselle
Rosemont
Roseville
Rosiclare
Rossville
RoundLake
Round Lake Beach
Round Lake Heights
Round Lake Park
Roxana
Royal
Royal Lakes
Royalton
Ruma
Rushville
Russellville
Rutland
Sadorus
Sailor Springs
Salem
Sammons Point
SanJose
Sandoval
Sandwich
Sauget
Sauk Village
Saunemin
Savanna
Savoy
Sawyerville
Saybrook
Scales Mound
Schaumburg
Schiller Park
Schram City
Sciota
Scottville
Seaton
Seatonville
Secor
Seneca
Serena
Sesser
Shabbona
Shannon
Shawneetown
Sheffield
Shelbyville
Sheldon
Sheridan
Sherman
Sherrard
Shiloh
Shorewood
Shumway
Sibley
Sidell
Sidney
Sigel
Silvis
Simpson
Sims
Skokie
Sleepy Hollow
Smithboro
Smithfield
Smithton
SoBeloit
Somonauk
Sorento
South Barrington
South Beloit
South Chicago Heights
South Elgin
South Holland
South Jacksonville
South Pekin
South Roxana
South Wayne
South Wilmington
Southern View
Sparland
Sparta
Spaulding
Spillertown
SpringBay
SpringGrove
Spring Valley
Springerton
Springfield
St John
StLouis
St.Anne
St.Augustine
St.Charles
St.David
St.Elmo
St.Francisville
St.Jacob
St.Johns
St.Joseph
St.Libory
St.Peter
Standard
Standard City
Stanford
Staunton
Ste.Marie
Steeleville
Steger
Sterling
Steward
Stewardson
Stickney
Stillman Valley
Stockton
StonePark
Stonefort
Stonington
Stoy
Strasburg
Strawn
Streamwood
Streator
Stronghurst
Sublette
Sugar Grove
Sullivan
Summerfield
Summit
Sumner
Sun River Terrace
Sutter
Swansea
Sycamore
Symerton
Table Grove
Tallula
Tamaroa
Tamms
Tampico
Taylor Springs
Tennessee
Teutopolis
Thawville
Thayer
Thebes
Third Lake
Thomasboro
Thompsonville
Thomson
Thornton
Tilden
Tilton
Timberlane
Time
TinleyPark
Tiskilwa
Toledo
Tolono
Toluca
Tonica
Topeka
Tovey
Towanda
Tower Hill
Tower Lakes
Tremont
Trenton
Trevor
Trout Valley
Troy
Troy Grove
Twin Lakes
Ullin
Union
Union City
Union Hill
University Park
Urbana
Ursa
Utica
Valier
Valley City
Valmeyer
Vandalia
Varna
Venedy
Venice
Vergennes
Vermilion
Vermont
Vernon
Vernon Hills
Verona
Versailles
Victoria
Vienna
Villa Grove
Villa Park
Viola
Virden
Virgil
Virginia
Volo
Wadsworth
Waggoner
Walnut
Walnut Hill
Walshville
Waltonville
Wamac
Wapella
Warren
Warrensburg
Warrenville
Warsaw
Washburn
Washington
Washington Park
Wataga
Waterloo
Waterman
Watseka
Watson
Wauconda
Waukegan
Waverly
Wayne
Wayne City
Waynesville
Weldon
Wellington
Wenona
Wenonah
West Brooklyn
West Chicago
West City
West Dundee
West Frankfort
West Haven
West Peoria
West Point
West Salem
Westchester
Western Springs
Westfield
Westmont
Westpoint
Westville
Wheaton
Wheeler
Wheeling
White City
White Hall
Whiteash
Williamsfield
Williamson
Williamsville
Willisville
Willow Hill
Willow Springs
Willowbrook
Wilmette
Wilmington(GreeneCounty)
Wilmington(WillCounty)
Wilsonville
Winchester
Windsor
Windsor(ShelbyCounty)
Winfield
Winnebago
Winnetka
Winslow
Winthrop Harbor
Witt
WolfLake
WonderLake
WoodDale
WoodRiver
Woodhull
Woodland
Woodlawn
Woodridge
Woodson
Woodstock
Worden
Worth
Wyanet
Wyoming
Xenia
Yale
Yates City
Yorkville
Zeigler
Zion
---------
Other
(n)
Invalid City , Please Select a Valid City
(n)
+
-
Specify the City
*
x
(n)
Panel 553
(n)
Drag and drop controls from the palette or from the form.
+
-
State
*
x
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
(n)
Panel 552
(n)
Drag and drop controls from the palette or from the form.
+
-
Zip Code
*
x
(n)
(n)
Panel 802
(n)
Drag and drop controls from the palette or from the form.
+
-
Employer/POA Email Address
*
x
(n)
Panel 803
(n)
Drag and drop controls from the palette or from the form.
(IDES notification mail will be sent electronically to this Email address)
(n)
(n)
Panel 85
(n)
Drag and drop controls from the palette or from the form.
+
-
Person to contact, if different from above
*
x
(n)
+
-
Contact Person's Telephone no.
*
Enter as:
###-###-####
###.###.####
###-#### or
###.####
(n)
Panel 86
(n)
Drag and drop controls from the palette or from the form.
+
-
Contact Person's Email Address
*
x
(n)
Panel 89
(n)
Drag and drop controls from the palette or from the form.
+
-
Contact Person's Street address
*
x
(n)
Panel 554
(n)
Drag and drop controls from the palette or from the form.
+
-
Contact Person's City or Town
*
x
(n)
Panel 553
(n)
Drag and drop controls from the palette or from the form.
+
-
Contact Person's State
*
x
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
(n)
Panel 552
(n)
Drag and drop controls from the palette or from the form.
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Contact Person's Zip Code
*
x
(n)
Panel 727
(n)
Drag and drop controls from the palette or from the form.
If, based on the individual's age and home address, he or she is a member of group 4 or 6 (as described under Members of Targeted Groups in the separate instructions), enter that group number (4 or 6)...................>
(n)
Panel 726
(n)
Drag and drop controls from the palette or from the form.
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*
x
(n)
+
+
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Date Applicant
x
(n)
Drag and drop controls from the palette or from the form.
Panel 99
(n)
Drag and drop controls from the palette or from the form.
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Gave information
*
x
(n)
Panel 97
(n)
Drag and drop controls from the palette or from the form.
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Was offered job
*
x
(n)
Panel 98
(n)
Drag and drop controls from the palette or from the form.
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Was hired
*
x
(n)
Panel 96
(n)
Drag and drop controls from the palette or from the form.
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Started job
*
x
(n)
Complete Only If Box 1 on Page 1 is Checked
(n)
Panel 112
(n)
Drag and drop controls from the palette or from the form.
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State and county or parish of job
*
x
(n)
Panel 106
(n)
Drag and drop controls from the palette or from the form.
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Checkbox 113
*
x
Check if the individual was not your employee on August 28, 2005, and this is the first time the employee has been hired by you since August 28, 2005.
(n)
Under penalties of perjury, I declare that the applicant provided the information on this form on or before the day a job was offered to the applicant and that the information I have furnished is, to the best of my knowledge, true, correct, and complete. Based on the information the job applicant furnished on page 1, I believe the individual is a member of a targeted group. I hereby request a certification that the individual is a member of a targeted group.
(n)
Panel 116
(n)
Drag and drop controls from the palette or from the form.
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Employer's Signature
*
x
Select check-box in lieu of your signature
(n)
Panel 811
(n)
Drag and drop controls from the palette or from the form.
+
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Name of Person Signing
*
x
(n)
Panel 117
(n)
Drag and drop controls from the palette or from the form.
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Title
*
x
(n)
Panel 114
(n)
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+
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Date
*
x
(n)
+
+
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Form 9061
x
(n)
Drag and drop controls from the palette or from the form.
Panel 131
(n)
Drag and drop controls from the palette or from the form.
Individual Characteristics Form(ICF)
Work Opportunity Tax Credit
(n)
Panel 130
(n)
Drag and drop controls from the palette or from the form.
U S Department of Labor
Employment and Training Administration
(n)
Panel 195
(n)
Drag and drop controls from the palette or from the form.
1. Control No. (For Agency use only)
(n)
Panel 150
(n)
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APPLICANT INFORMATION
(See instructions on reverse)
(n)
Panel 149
(n)
Drag and drop controls from the palette or from the form.
OMB No. 1205-0371
Expiration Date: November 30, 2016
(n)
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2. Date Received (For Agency Use only)
*
x
(n)
EMPLOYER INFORMATION
(n)
Panel 172
(n)
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3. Employer Name
*
x
(n)
Panel 174
(n)
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4(a). Employer Address
*
x
(n)
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4(b). Employer Telephone
*
Enter as:
###-###-####
###.###.####
###-#### or
###.####
(n)
Panel 171
(n)
Drag and drop controls from the palette or from the form.
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5. Employer Federal ID Number (EIN)
*
x
(n)
APPLICANT INFORMATION
(n)
Panel 387
(n)
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6. Applicant Name (Last, First, MI)
*
x
(n)
Panel 384
(n)
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7. Social Security Number.
*
x
(n)
Panel 382
(n)
Drag and drop controls from the palette or from the form.
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8. Have you worked for the above employer before?
*
x
Yes
No
(n)
WOTC application cannot be submitted if the Applicant has worked with the same employer earlier
(n)
APPLICANT CHARACTERISTICS FOR WOTC TARGET GROUP CERTIFICATION
(n)
Panel 203
(n)
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9. Employment Start Date
*
x
(n)
Panel 204
(n)
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10. Starting Wage(Per Hour)
*
x
(n)
Panel 389
(n)
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11(a). Position
*
x
(n)
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11(b). Occupation
*
x
Management
Business & Financial Operations
Computer & Math
Architecture & Engineering
Life, Physical & Social Sciences
Community & Social Services
Legal
Education, Training & Library
Arts, Design, Entertainment Sports & Media
Healthcare practitioners
Healthcare Support
Protective Services
Food Preparation & Serving-related
Bldg. & Grounds Cleaning & Maintenance
Personal Care & Services
Sales & related Occupations
Office & Administrative support
Farming, Fishing & Forestry
Construction & Extraction
Installation, Maintenance & Repair
Production
Transportation & Material moving
Military Specific
(n)
+
+
-
x
(n)
Drag and drop controls from the palette or from the form.
Panel 393
(n)
Drag and drop controls from the palette or from the form.
(n)
+
-
12. Are you at least age 16, but under age 40?
*
x
Yes
No
(n)
+
-
If YES,
enter your
date of birth
(mm/dd/yyyy)
*
x
+
+
-
x
(n)
Drag and drop controls from the palette or from the form.
Panel 393
(n)
Drag and drop controls from the palette or from the form.
+
-
13. Are you a Veteran of the U.S. Armed Forces?
*
x
Yes
No
(n)
If NO,
go to Box 14.
(n)
+
-
If YES,
are you a member of a family that received SNAP (Food Stamps) benefits the 15 months for at least 3 months during before you were hired?
*
x
Yes
No
(n)
+
-
If YES,
enter name of
primary recipient
*
x
(n)
+
-
city and state
where benefits were received
*
x
(n)
+
-
OR,
are you a veteran entitled to compensation for a service-connected disability?
*
x
Yes
No
(n)
+
-
If YES,
were you discharged or released from active duty within the year before you were hired?
*
x
Yes
No
(n)
+
-
OR,
were you unemployed for a combined period of at least 6 months during the year before you were hired?
*
x
Yes
No
(n)
+
+
-
x
(n)
Drag and drop controls from the palette or from the form.
Panel 393
(n)
Drag and drop controls from the palette or from the form.
(n)
+
-
14. Are you a member of a family that received Supplemental Nutritional Assistance Program (SNAP) (Food Stamps) benefits
for the 6 months before you were hired?
*
x
Yes
No
(n)
+
-
OR,
received SNAP benefits for at least a 3-month period within the last 5 months But you are no longer receiving them?
*
x
Yes
No
(n)
+
-
If YES to either question,
enter name of
primary recipient
*
x
(n)
+
-
city and state
where benefits were received
*
x
(n)
+
+
-
x
(n)
Drag and drop controls from the palette or from the form.
Panel 393
(n)
Drag and drop controls from the palette or from the form.
+
-
15. Were you referred to an employer by a Vocational Rehabilitation Agency approved by a State?
*
x
Yes
No
(n)
+
-
OR,
by an Employment Network under the Ticket to Work Program?
*
x
Yes
No
(n)
+
-
OR,
by the Department of Veterans Affairs?
*
x
Yes
No
(n)
+
+
-
x
(n)
Drag and drop controls from the palette or from the form.
Panel 393
(n)
Drag and drop controls from the palette or from the form.
+
-
16. Are you a member of a family that received TANF assistance for at least the last 18 months before you were hired?
*
x
Yes
No
(n)
+
-
OR,
are you a member of a family that received TANF benefits for any 18 months beginning after August 5, 1997, and the
earliest 18-month period beginning after August 5, 1997, ended within 2 years before you were hired?
*
x
Yes
No
(n)
+
-
OR,
did your family stop being eligible for TANF assistance within 2 years before you were hired because a Federal or state
law limited the maximum time those payments could be made?
*
x
Yes
No
(n)
+
-
If NO,
are you a member of a family that received TANF assistance for any 9 months during the 18 month period before you were hired?
*
x
Yes
No
(n)
+
-
If YES, to any question,
enter name of
primary recipient
*
x
(n)
+
-
city and state
where benefits were received
*
x
(n)
+
+
-
x
(n)
Drag and drop controls from the palette or from the form.
Panel 393
(n)
Drag and drop controls from the palette or from the form.
+
-
17. Were you convicted of a felony or released from prison after a felony conviction during the year before you were hired?
*
x
Yes
No
(n)
+
-
If YES,
enter
date of conviction
*
x
(n)
+
-
date of release
*
x
(n)
+
-
Check One-------Was this a
*
x
Federal
Or a State Conviction
(n)
+
+
-
x
(n)
Drag and drop controls from the palette or from the form.
Panel 393
(n)
Drag and drop controls from the palette or from the form.
+
-
18. Do you live, and plan to continue living, in an Empowerment Zone or Renewal Community?
*
x
Yes
No
(n)
+
-
18. Do you live in an Empowerment Zone or Rural Renewal County (RRC)?
*
x
Yes
No
(n)
+
-
If YES,
enter
name of the RRC:
(Select 'Other' if out of State)
*
x
Alexander
Edwards
Franklin
Gallatin
Greene
Hancock
Hardin
Jasper
Knox
McDonough
Montgomery
Pulaski
Randolph
Richland
Scott
Warren
Wayne
White
----------
Other
(n)
Invalid RRC Name , Please Select a Valid RRC Name
(n)
+
-
Specify the RRC:
*
x
(n)
+
+
-
x
(n)
Drag and drop controls from the palette or from the form.
Panel 393
(n)
Drag and drop controls from the palette or from the form.
+
-
19. Do you live in an Empowerment Zone and are at least age 16, but not yet 18, on your hiring date?
*
x
Yes
No
(n)
+
+
-
x
(n)
Drag and drop controls from the palette or from the form.
Panel 393
(n)
Drag and drop controls from the palette or from the form.
+
-
20. Did you receive Supplemental Security Income (SSI) benefits for any month ending within 60 days before you were hired?
*
x
Yes
No
(n)
+
+
-
x
(n)
Drag and drop controls from the palette or from the form.
Panel 393
(n)
Drag and drop controls from the palette or from the form.
+
-
21. Are you a veteran unemployed for a combined period of at least 6 months (whether or not consecutive) during the year before you were hired?
*
x
Yes
No
(n)
+
-
OR
were you discharged or released from active duty in the Armed Forces for a service-connected disability?
*
x
Yes
No
(n)
+
-
If YES,
where you discharged or released from active duty in the Armed forces at any time 5-year period ending on the hiring date?
*
x
Yes
No
(n)
+
-
If YES,
did you receive unemployment compensation for not less than four weeks during the one-year period ending on your hiring date?
*
x
Yes
No
(n)
+
+
-
x
(n)
Drag and drop controls from the palette or from the form.
Panel 393
(n)
Drag and drop controls from the palette or from the form.
+
-
22. Are you a veteran unemployed for a combined period of at least 4 weeks but less than 6 months (whether or not consecutive) during the year before you were hired?
*
x
Yes
No
(n)
+
-
If YES,
did you not regularly attend any secondary, technical, or post-secondary school during the 6-month period before your hiring date?
*
x
Yes
No
(n)
+
-
If YES
were you not regularly employed during that 6-month period?
*
x
Yes
No
(n)
+
-
If YES,
were you not employable because you lacked basic skills?
*
x
Yes
No
(n)
+
+
-
x
(n)
Drag and drop controls from the palette or from the form.
Panel 393
(n)
Drag and drop controls from the palette or from the form.
+
-
23. Are you an individual who is or was in a period of unemployement that is at least 27 consecutive weeks the day before you began to work for the employer, or if earlier, the day you completed IRS Form 8850, the Prescreening Form?
*
x
Yes
No
(n)
+
-
If YES,
did you receive unemployment compensation/benefits under State or Federal law during a period of unemployment?
*
x
Yes
No
(n)
+
-
24.
Sources used to document eligibility:
(Employers/Consultants
: List all documentation provided or forthcoming. SWAs:List all documentation used
in determining target group eligibility and enter your initials and date when determination was made.)
*
x
(n)
+
-
*
x
I certify that this information is true and correct to the best of my knowledge. I understand that the information above may be subject to verification.
(n)
+
-
*
x
I certify that I have and will hold onto a signed Self-Attestation Form (ETA Form 9175) from this applicant.
(n)
+
+
-
x
(n)
Drag and drop controls from the palette or from the form.
Panel 446
(n)
Drag and drop controls from the palette or from the form.
+
-
25(a). Signature
*
x
Check in lieu of your Signature
(n)
Panel 302
(n)
Drag and drop controls from the palette or from the form.
+
-
25. (b) Indicate with a TICK who signed the form:
*
x
Employer
Consultant
SWA
Participating Agency
Applicant
Parent/Guardian (if applicant is a minor)
(n)
Panel 301
(n)
Drag and drop controls from the palette or from the form.
+
-
Date
*
x
(n)
(n)
Submit
Cancel