WOTC Online Form

+ + - Form 8850 x

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Form: 8850 (Rev. January 31, 2020)
Department of the Treasury
Internal Revenue Service

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Pre-Screening Notice and Certification Request for the Work Opportunity Credit

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OMB No. 1545-1500

Job applicant: Fill in the lines below and check any boxes that apply.

+ - Your First Name * x

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+ - Middle Initial * x

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+ - Last Name * x

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+ - Social Security Number(enter 9 digits, no dashes) * x

+ - Street address where you live * x

+ - Applicant Street Address2 * x

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+ - City or Town (Select 'Other' if out of State) * x

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+ - State * x

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+ - Zip Code * x

Invalid City , Please Select a Valid City

+ - Specify the City * x

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+ - County (Select 'Other' if out of State) * x

Invalid County , Please Select a Valid County

+ - Specify the County * x

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+ - Telephone Number

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+ - Email Address * x

+ - If you are under age 40, enter your date of birth (mm/dd/yyyy) * x

+ - * x

Check here if you received a conditional certification from the state workforce agency (SWA) or a participating local agencyfor the work opportunity credit.

+ - Checkbox 54 * x

Check here if any of the following statements apply to you.

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.

+ - 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.

+ - 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.

+ - 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.

+ - Checkbox 56 * x

Check here if you are a member of a family that:

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.

+ - 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.

Signature---All Applicants Must Sign

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.

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+ - Job applicant's signature * x

Select check-box in lieu of your signature

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+ - Date * x

For Employer's Use Only

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+ - Employer's Name * x

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+ - Telephone Number *

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+ - EIN(enter 9 digits,no dashes) *

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+ - Street Address * x

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+ - City or Town (Select 'Other' if out of State) * x

Invalid City , Please Select a Valid City

+ - Specify the City * x

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+ - State * x

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+ - Zip Code * x

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+ - Employer/POA Email Address * x

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(IDES notification mail will be sent electronically to this Email address)

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+ - Person to contact, if different from above * x

+ - Contact Person's Telephone no. *

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+ - Contact Person's Email Address * x

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+ + - x

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+ - 25(a). Signature * x

Check in lieu of your Signature

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+ - 25. (b) Indicate with a TICK who signed the form: * x

Employer

Consultant

SWA

Participating Agency

Applicant

Parent/Guardian (if applicant is a minor)

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+ - Date * x