OMB No. 1545-1500

Form 8850

Department of the Treasury

Internal Revenue Service

If you received a conditional certification from the state employment security agency (SESA) or a participating local

agency, check the box on this line, skip item 2, and sign below ©

1

2 Do any of the following statements apply to you?

I am a member of a family that has received assistance from Aid to Families with Dependent Children (AFDC) or a successor

program for at least a 9-month period within the last 18 months.

Cat. No. 22851L

Work Opportunity Credit Pre-Screening Notice

and Certification Request

Form 8850 (9-96)

(September 1996)

Job Applicant Information

Name

Street address where you live

City or town, state, and ZIP code

● Assistance from AFDC or a successor program for at least a 9-month period within the last 21 months, OR

● Food stamps for at least a 3-month period within the last 15 months.

● Received food stamps for the last 6 months, OR

Job applicant’s signature ©

For Employer’s Use Only

Employer’s name

City or town, state, and ZIP code

DATE OF:

Date of birth (month, day, year)

Social security number ©

/ /

a

b I am a veteran and am a member of a family that received:

c I was referred here by a rehabilitation agency approved by the state or the Department of Veterans Affairs.

d I am a member of a family that:

I was convicted of a felony AND within the past year was either convicted or released from prison AND during the last

6 months I was a member of a low-income family.

e

● 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.

Telephone no.

Street address

Under penalties of perjury, I declare that I 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 above, 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.

Interview Job offer Hiring Job starting

Employer’s signature ©

Date / /

// // / /

/ /

/ /

Title Date

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

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 on page 2), enter that group number (4 or 6) ©

Telephone no. () -

Yes No

()-

Person to contact, if different from above

City or town, state, and ZIP code

Telephone no.

Street address

()-
Form 8850 (9-96) Page 2

Section references are to the Internal

Revenue Code unless otherwise noted.

Privacy Act and Paperwork

Reduction Act Notice

Section 51(d)(11) permits a prospective

employer to request you 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. You are not required to

complete this form, but failure to do so

may affect your chances of being hired.

Routine uses of this form include giving it

to the state employment security agency

(SESA), which will contact appropriate

sources to confirm that you are a member

of one of the targeted groups you

indicated on the form. 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 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.

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.

The times needed to complete and file

this form will vary depending on individual

circumstances. The estimated average time

is:

Recordkeeping 2 hr., 32 min.

Learning about the law

or the form 37 min.

Preparing and sending this form

to the SESA 33 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 Tax Forms Committee,

Western Area Distribution Center, Rancho

Cordova, CA 95743-0001.

DO NOT send this form to this address.

Instead, see When and Where To File later.

General Instructions

Purpose of Form

Employers use Form 8850 to pre-screen

and as a written request to a SESA to

certify an individual as a member of a

targeted group for purposes of qualifying

for the work opportunity credit. The work

opportunity credit applies only in the case

of individuals who begin work for the

employer after September 30, 1996, and

before October 1, 1997. See the 1996

Form 5884, Work Opportunity Credit, for

more details.

Who Should Complete and

Sign the Form

The job applicant furnishes information to

the employer on or before the day a job

offer is made. This information is entered

on Form 8850. Based on this information,

the employer determines whether or not he

or she believes the applicant is a member

of a targeted group (as defined under

Members of Targeted Groups below). If

the employer believes the applicant is a

member of a targeted group, the employer

completes the rest of the form no later

than the day the job offer is made. Both

the job applicant and employer must sign

Form 8850 no later than the date for

submitting the form to the SESA.

When and Where To File

Do not file Form 8850 with the IRS.

Instead, submit it to the SESA no later

than the 21st day after the job applicant

begins work for the employer.

Recordkeeping

Keep copies of Forms 8850, along with

any transmittal letters that you submit to

the SESA, as long as they may be needed

for the administration of the Internal

Revenue Code provisions relating to the

work opportunity credit. Records that

support this credit usually must be kept for

3 years from the date any income tax

return claiming the credit is due or filed,

whichever is later.

Members of Targeted

Groups

A job applicant may be certified as a

member of a targeted group if he or she is:

1. A member of a family receiving

assistance under a state plan approved

under part A of title IV of the Social

Security Act relating to Aid to Families with

Dependent Children (AFDC) or any

successor program. Generally, the

assistance must be received for at least a

9-month period during the 18 months

ending on the hiring date. See section

51(d)(2).

2. A veteran who is a member of a

family receiving assistance under either

(a) the program described in 1 above for

generally at least a 9-month period during

the 21 months ending on the hiring date or

(b) the Food Stamp program for generally

at least a 3-month period during the 15

months ending on the hiring date. See

section 51(d)(3). To be considered a

veteran, the applicant must (a) have

served on active duty (not including

training) in the Armed Forces of the United

States for more than 180 days OR have

been discharged for a service-connected

disability, AND (b) not have a period of

active duty (not including training) of more

than 90 days that ended during the 60

days ending on the hiring date.

3. An ex-felon who (a) has been

convicted of a felony under any Federal or

state law, (b) is hired not more than 1 year

after the latest conviction or release from

prison, and (c) is a member of a family that

had income on an annual basis of 70% or

less of the Bureau of Labor Statistics lower

living standard during the 6 months

preceding the earlier of the month the

income determination occurs or the month

in which the hiring date occurs.

4. An individual who has attained age 18

but not age 25 on the hiring date and lives

in an empowerment zone or enterprise

community.

The Secretary of Housing and Urban

Development (HUD) designated portions of

the following cities as urban empowerment

zones: Atlanta, GA (9.29 square miles);

Baltimore, MD (6.8 square miles);

Philadelphia, PA/Camden, NJ (4.4 square

miles); Chicago, IL (14.33 square miles);

Detroit, MI (18.3 square miles); and New

York City, NY (Manhattan and the Bronx)

(7.6 square miles). The Secretary of

Agriculture (USDA) designated the

following rural empowerment zones: the

Kentucky Highlands (counties of Clinton,

Jackson, and Wayne); Mid-Delta,

Mississippi (counties of Bolivar, Sunflower,

Leflore, Washington, Humphreys, and

Holmes); and Rio Grande Valley, Texas

(counties of Starr, Cameron, Hidalgo, and

Willacy). The boundaries of the rural

empowerment zones follow the boundaries

of these counties. There are 65 urban and

30 rural enterprise communities located in

35 states and the District of Columbia.

There are no empowerment zones or

enterprise communities in Puerto Rico,

Guam, or any U.S. possession.

You may call HUD at 1-800-998-9999 for

information on the six urban empowerment

zones, or the USDA at 1-800-645-4712

about the rural empowerment zones. On

the Internet, you can find the EZ/EC Home

Page at http://www.ezec.gov. Your local

SESA has information on where the

enterprise communities are located. Also,

many enterprise communities have their

own web sites.

5. An individual who has a physical or

mental disability that results in a

substantial handicap to employment and

who was referred to the employer upon

completion of (or while receiving)

rehabilitation services under a state

rehabilitation plan or a program approved

by the Department of Veterans Affairs.

6. An individual who performs services

for the employer between May 1 and

September 15, has attained age 16 but not

age 18 on the hiring date (or if later, on

May 1), has never worked for the employer

before, and lives in an empowerment zone

or enterprise community.

7. An individual who has attained age 18

but not age 25 who is a member of a

family that has received food stamps for

the 6-month period ending on the hiring

date or who is a member of a family no

longer eligible for such assistance under

section 6(o) of the Food Stamp Act of

1977 and the family received food stamps

for at least 3 months of the 5-month period

ending on the hiring date.

Instructions for

Employer