OMB No. 1545-1500

Form 8850

Department of the Treasury

Internal Revenue Service

Check here if you received a conditional certification from the state employment security agency (SESA) 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 last 18 months.

Cat. No. 22851L

Pre-Screening Notice and Certification Request for

the Work Opportunity Credit

Form 8850 (Rev. 01-07)

(Rev. January 2007)

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

a Received food stamps for the last 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 food stamps for at least a 3-month period within the last 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:

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

b Received food stamps for at least 3 of the last 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.

Telephone number ( ) -

© 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 last 18 months, or

● Stopped being eligible for TANF payments within the last 2 years because federal or state law limited the maximum

time those payments could be made.

Work Opportunity Credit

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

4

All Applicants

1 Check here if 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 within the last 2 years, or
Form 8850 (Rev. 01-07) 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 completed 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 employment security

agency (SESA), 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

The time needed to complete and file

this form will vary depending on

individual circumstances. The estimated

average time is:

Recordkeeping 5 hrs., 30 min.

Learning about the law

or the form 24 min.

Preparing and sending this form

to the SESA 30 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-6406, 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. 01-07)

civil and criminal litigation, to the

Department of Labor for oversight of the

certifications performed by the SESA,

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 last 18 months.

Cat. No. 22851L

Pre-Screening Notice and Certification Request for

the Work Opportunity Credit

Form 8850 (Rev. 2-07)

(Rev. February 2007)

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

a Received food stamps for the last 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 food stamps for at least a 3-month period within the last 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:

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

b Received food stamps for at least 3 of the last 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.

Telephone number ( ) -

© 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 last 18 months, or

● Stopped being eligible for TANF payments within the last 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 within the last 60 days.

4

Signature—All Applicants Must Sign

1 Check here if 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 within the last 2 years, or
Form 8850 (Rev. 2-07) 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 completed 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 5 hrs., 30 min.

Learning about the law

or the form 24 min.

Preparing and sending this form

to the SWA 30 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-6406, 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. 2-07)

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. 6-07)

(Rev. June 2007)

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

a Received 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 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.

b Received 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.

Telephone number ( ) -

© 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, 2007, 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.
Form 8850 (Rev. 6-07) 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 completed 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 5 hrs., 30 min.

Learning about the law

or the form 24 min.

Preparing and sending this form

to the SWA 30 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-6406, 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. 6-07)

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