+ + - x

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

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

OMB No. 1545-1500
Job applicant: Fill in the lines below and check any boxes that apply.
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.
+ + - x
+ - * x
+ - * x
+ - * x
+ - * x
+ - * x
+ - * x
+ - * x
Invalid City , Please Select a Valid City
+ - * x
Invalid County , Please Select a Valid County
+ - * x
+ -
+ - * x
+ - * x
+ - * x

  • 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.
+ - * x
+ - * x
+ - * x
+ - * x

  • 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.
+ - * x

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.
+ - * x
+ - * x

For Employer's Use Only
+ - * x
+ - *
+ - *
+ - * x
Invalid City , Please Select a Valid City
+ - * x
+ - * x

(IDES notification mail will be sent electronically to this Email address)
+ - * x
+ - *
+ - * x
+ - * x
+ - * x
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)...................>
+ - * x
+ + - x
+ - * x
+ - * x
+ - * x
+ - * x
Complete Only If Box 1 on Page 1 is Checked
+ - * x
+ - * x
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.
+ - * x
+ - * x
+ - * x
+ - * x
+ + - x

Individual Characteristics Form(ICF)
Work Opportunity Tax Credit

U S Department of Labor
Employment and Training Administration
1. Control No. (For Agency use only)

APPLICANT INFORMATION
(See instructions on reverse)

OMB No. 1205-0371
Expiration Date: November 30, 2016
+ - * x

EMPLOYER INFORMATION
+ - * x
+ - * x
+ - *
+ - * x

APPLICANT INFORMATION
+ - * x
+ - * x
+ - * x
WOTC application cannot be submitted if the Applicant has worked with the same employer earlier

APPLICANT CHARACTERISTICS FOR WOTC TARGET GROUP CERTIFICATION
+ - * x
+ - * x
+ - * x
+ + - x
+ - * x
+ + - x
+ - * x
If NO, go to Box 14.
+ - x
+ - x
+ - x
+ - * x
+ - x
+ - * x
+ + - x
+ - * x
+ - * x
+ - x
+ - x
+ + - x
+ - * x
+ - * x
+ - * x
+ + - x
+ - * x
+ - * x
+ - * x
+ - * x
+ - x
+ - x
+ + - x
+ - * x
+ + - x
+ - * x
+ - * x
Invalid RRC Name , Please Select a Valid RRC Name
+ - * x
+ + - x
+ - * x
+ + - x
+ - * x
+ + - x
+ - * x
+ - * x
+ - * x
+ - * x
+ + - x
+ - * x
+ - * x
+ - * x
+ - * x
+ + - x
+ - * x
+ - x
+ - * x
+ - * x
+ - * x
+ + - x
+ - * x
+ - * x
+ - * x