IRS Form 8850 (Rev. March 2016) · 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. Complete only this side.

Your Name

Social Security Number

Street Address Where You Live

City or Town, State, and ZIP Code

County

Telephone Number

If under age 40, date of birth (month, day, year)

Check any boxes that apply to you:

1 — Check here if you received a conditional certification from the state workforce agency (SWA) or a participating local agency for the work opportunity credit. 2 — Check here if any of the following apply: TANF assistance 9 of past 18 months; OR veteran whose family received SNAP for a 3-month period in past 15 months; OR referred by a state rehab agency, a Ticket to Work employment network, or the VA; OR age 18–39 in a family that received SNAP for the past 6 months (or 3 of past 5, no longer eligible); OR convicted of a felony or released from prison for a felony in the past year; OR received SSI in the past 60 days; OR veteran unemployed 4 weeks–6 months in the past year. 6 — Check here if you are a member of a family that received TANF payments for at least the past 18 months; OR for any 18 months beginning after Aug 5, 1997 (earliest such period ended in past 2 years); OR stopped being eligible in past 2 years due to a maximum-time limit. 7 — 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.

Page 2 — WOTC Screening Questionnaire

Please fill in these forms slowly and legibly. (Form Updated 01/01/2020)

Company Name

Company EIN Number

Have you ever worked for this Employer before? Are you a Re-hire? Yes No

Are you under age 40? Yes No

Have you been unemployed for at least 27 weeks, and collected Unemployment Insurance? Yes No

Are you a Veteran of the US Armed Forces? Yes No

If yes (Veteran):

Are you a member of a family that received SNAP (Food Stamps Benefits)? Yes No

Are you entitled to compensation for a service-connected disability? Yes No

Were you discharged from active duty within the last year? Yes No

Were you unemployed for a combined total of 6 months before you were hired? Yes No

Have you, or your family, received SNAP benefits in the 6 months before you were hired? Yes No

Or received SNAP Benefits for at least a 3-month period, but you are no longer receiving it? Yes No

If yes, Name of Primary Recipient

And City, State where benefits were received

Are you a member of a family that received TANF assistance for at least 18 months before you were hired? Yes No

Or, did your family stop being eligible for TANF assistance within 2 years before being hired (max time reached)? Yes No

If yes, Name of Primary Recipient

And City, State where benefits were received

Did you receive Supplemental Security Income (SSI Benefits) for any month, ending within the 60 days, before you were hired? Yes No

Were you convicted of a Felony during the year before you were hired? Yes No

Were you referred to an employer by:

A Vocational Rehab Agency approved by the state? Yes No

An Employment Network under the Ticket to Work Program? Yes No

The Dept. of Veteran Affairs? Yes No

Print Name

Social Security #

Date of Birth

By signing this form, I hereby authorize any agency, organization, Social Security Administration, Department of Veterans Affairs, or individuals, to supply verification of information as may be needed to determine tax credit eligibility to my employer, employer representative (TC Services USA, Inc. dba WOTC.com), or the Department of Labor. I also understand that my responses are used, in part or in full, to complete the IRS Form 8850 and any other documents pertaining to the WOTC Program, and that modifications can be made by my employer, or employer representative, in order to enable the verification screening process as required by some states. This information will not in any way affect my employment.

Employment Start Date

Starting Wage

Position

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