OMB No. 1545-1500

Form 8850

Department of the Treasury

Internal Revenue Service

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

3

● 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.

Cat. No. 22851L

Pre-Screening Notice and Certification Request for

the Work Opportunity Credit

Form 8850 (Rev. 5-2009)

(Rev. May 2009)

Job applicant: Fill in the lines below and check any boxes that apply. Complete only this side.

Your name

Street address where you live

City or town, state, and ZIP code

Received SNAP benefits (food stamps) for the past 6 months, or

Job applicant’s signature ©

If you are under age 40, enter your date of birth (month, day, year)

Social security number ©

/ /

● 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:

● During the past year, I was convicted of a felony or released from prison for a felony.

Received SNAP benefits (food stamps) for at least 3 of the past 5 months, but is no longer eligible to receive them.

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.

Date / /

For Privacy Act and Paperwork Reduction Act Notice, see page 2.

County

© See separate instructions.

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

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

● Received TANF payments for at least the past 18 months, 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.

● I received supplemental security income (SSI) benefits for any month ending during the past 60 days.

5

Signature—All Applicants Must Sign

1 Check here if you are completing this form before August 28, 2009, and you lived in the area impacted by Hurricane Katrina 

on August 28, 2005. If so, please enter the address, including county or parish and state where you lived at that time.

● 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

Check here if you are a veteran entitled to compensation for a service-connected disability and, during the past year,

you were:

● Discharged or released from active duty in the U.S. Armed Forces, or

4

● Unemployed for a period or periods totaling at least 6 months.

Telephone number ( ) -

● I am a veteran and I was discharged or released from active duty in the U.S. Armed Forces during the past 5 years

and, for at least 4 weeks during the past year, I received unemployment compensation.

● I am at least age 16 but not age 25 or older, and:

During the past 6 months, I have not attended a secondary, technical, or post-secondary school for more than

an average of 10 hours per week, not counting periods during which the school was closed for scheduled

vacations, and

b During the past 6 months, if I was employed, during each consecutive 3-month period within the past 6 months,

I earned less than I would have earned if I had worked for the applicable minimum wage 30 hours every week

during the 3-month period, and

a

a

b

c I do not have a certificate of graduation from a secondary school or a General Education Development (GED)

certificate or I have a certificate that was awarded at least 6 months ago and I have not held a job or been

admitted to a technical or post-secondary school since I received the certificate.
Form 8850 (Rev. 5-2009) Page 2

For Employer’s Use Only

Employer’s name

City or town, state, and ZIP code

Date applicant:

Telephone no.

Street address

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.

Gave

information

Was

offered job

Was

hired

Started

job

Employer’s signature ©

/ / / / / /

/ /

/ /

Title Date

EIN ©

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) ©

( ) -

Person to contact, if different from above

City or town, state, and ZIP code

Telephone no.

Street address

( ) -

Privacy Act and

Paperwork Reduction

Act Notice

Section 51(d)(13) permits a prospective

employer to request the applicant to

complete this form and give it to the

prospective employer. The information

will be used by the employer to

complete the employer’s federal tax

return. Completion of this form is

voluntary and may assist members of

targeted groups in securing employment.

Routine uses of this form include giving

it to the state workforce agency (SWA),

which will contact appropriate sources

to confirm that the applicant is a

member of a targeted group. This form

may also be given to the Internal

Revenue Service for administration of

the Internal Revenue laws, to the

Department of Justice for civil and

The time needed to complete and file

this form will vary depending on

individual circumstances. The estimated

average time is:

Recordkeeping 3 hrs., 16 min.

Learning about the law

or the form 46 min.

Preparing and sending this form

to the SWA 42 min.

If you have comments concerning the

accuracy of these time estimates or

suggestions for making this form

simpler, we would be happy to hear

from you. You can write to the Internal

Revenue Service, Tax Products

Coordinating Committee,

SE:W:CAR:MP:T:T:SP, 1111 Constitution

Ave. NW, IR-6526, Washington, DC

20224.

Do not send this form to this address.

Instead, see When and Where To File in

the separate instructions.

Section references are to the Internal

Revenue Code.

Form 8850 (Rev. 5-2009)

criminal litigation, to the Department of

Labor for oversight of the certifications

performed by the SWA, and to cities,

states, and the District of Columbia for

use in administering their tax laws. We

may also disclose this information to

other countries under a tax treaty, to

federal and state agencies to enforce

federal nontax criminal laws, or to

federal law enforcement and intelligence

agencies to combat terrorism.

You are not required to provide the

information requested on a form that is

subject to the Paperwork Reduction Act

unless the form displays a valid OMB

control number. Books or records

relating to a form or its instructions must

be retained as long as their contents

may become material in the

administration of any Internal Revenue

law. Generally, tax returns and return

information are confidential, as required

by section 6103.

State and

county or

parish of job

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.

Complete Only If Box 1 on Page 1 is Checked
OMB No. 1545-1500

Form 8850

Department of the Treasury

Internal Revenue Service

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

3

● 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.

Cat. No. 22851L

Pre-Screening Notice and Certification Request for

the Work Opportunity Credit

Form 8850 (Rev. 8-2009)

(Rev. August 2009)

Job applicant: Fill in the lines below and check any boxes that apply. Complete only this side.

Your name

Street address where you live

City or town, state, and ZIP code

Received SNAP benefits (food stamps) for the past 6 months, or

Job applicant’s signature ©

If you are under age 40, enter your date of birth (month, day, year)

Social security number ©

/ /

● 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:

● During the past year, I was convicted of a felony or released from prison for a felony.

Received SNAP benefits (food stamps) for at least 3 of the past 5 months, but is no longer eligible to receive them.

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.

Date / /

For Privacy Act and Paperwork Reduction Act Notice, see page 2.

County

© See separate instructions.

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

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

● Received TANF payments for at least the past 18 months, 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.

● I received supplemental security income (SSI) benefits for any month ending during the past 60 days.

5

Signature—All Applicants Must Sign

1 Check here if you are completing this form before August 28, 2009, and you lived in the area impacted by Hurricane Katrina 

on August 28, 2005. If so, please enter the address, including county or parish and state where you lived at that time.

● 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

Check here if you are a veteran entitled to compensation for a service-connected disability and, during the past year,

you were:

● Discharged or released from active duty in the U.S. Armed Forces, or

4

● Unemployed for a period or periods totaling at least 6 months.

Telephone number ( ) -

● I am a veteran and I was discharged or released from active duty in the U.S. Armed Forces during the past 5 years

and, for at least 4 weeks during the past year, I received unemployment compensation.

● I am at least age 16 but not age 25 or older, and:

During the past 6 months, I have not attended a secondary, technical, or post-secondary school for more than

an average of 10 hours per week, not counting periods during which the school was closed for scheduled

vacations, and

b During the past 6 months, if I was employed, during each consecutive 3-month period within the past 6 months,

I earned less than I would have earned if I had worked for the applicable minimum wage 30 hours every week

during the 3-month period, and

a

a

b

c I do not have a certificate of graduation from a secondary school or a General Education Development (GED)

certificate or I have a certificate that was awarded at least 6 months ago and I have not held a job (other than

occasionally) or been admitted to a technical or post-secondary school since I received the certificate.
Form 8850 (Rev. 8-2009) Page 2

For Employer’s Use Only

Employer’s name

City or town, state, and ZIP code

Date applicant:

Telephone no.

Street address

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.

Gave

information

Was

offered job

Was

hired

Started

job

Employer’s signature ©

/ / / / / /

/ /

/ /

Title Date

EIN ©

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) ©

( ) -

Person to contact, if different from above

City or town, state, and ZIP code

Telephone no.

Street address

( ) -

Privacy Act and

Paperwork Reduction

Act Notice

Section 51(d)(13) permits a prospective

employer to request the applicant to

complete this form and give it to the

prospective employer. The information

will be used by the employer to

complete the employer’s federal tax

return. Completion of this form is

voluntary and may assist members of

targeted groups in securing employment.

Routine uses of this form include giving

it to the state workforce agency (SWA),

which will contact appropriate sources

to confirm that the applicant is a

member of a targeted group. This form

may also be given to the Internal

Revenue Service for administration of

the Internal Revenue laws, to the

Department of Justice for civil and

The time needed to complete and file

this form will vary depending on

individual circumstances. The estimated

average time is:

Recordkeeping 3 hrs., 16 min.

Learning about the law

or the form 46 min.

Preparing and sending this form

to the SWA 42 min.

If you have comments concerning the

accuracy of these time estimates or

suggestions for making this form

simpler, we would be happy to hear

from you. You can write to the Internal

Revenue Service, Tax Products

Coordinating Committee,

SE:W:CAR:MP:T:T:SP, 1111 Constitution

Ave. NW, IR-6526, Washington, DC

20224.

Do not send this form to this address.

Instead, see When and Where To File in

the separate instructions.

Section references are to the Internal

Revenue Code.

Form 8850 (Rev. 8-2009)

criminal litigation, to the Department of

Labor for oversight of the certifications

performed by the SWA, and to cities,

states, and the District of Columbia for

use in administering their tax laws. We

may also disclose this information to

other countries under a tax treaty, to

federal and state agencies to enforce

federal nontax criminal laws, or to

federal law enforcement and intelligence

agencies to combat terrorism.

You are not required to provide the

information requested on a form that is

subject to the Paperwork Reduction Act

unless the form displays a valid OMB

control number. Books or records

relating to a form or its instructions must

be retained as long as their contents

may become material in the

administration of any Internal Revenue

law. Generally, tax returns and return

information are confidential, as required

by section 6103.

State and

county or

parish of job

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.

Complete Only If Box 1 on Page 1 is Checked