Form 8850

(Rev. January 2013)

Department of the Treasury 

Internal Revenue Service 

Pre-Screening Notice and Certification Request for 

the Work Opportunity Credit

▶ Information about Form 8850 and its separate instructions is at www.irs.gov/form8850.

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

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 statements apply to you.

• 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.

3 Check here if you are a veteran and you were unemployed for a period or periods totaling at least 6 months during the past 

year.

4 Check here if you are a veteran entitled to compensation for a service-connected disability and you were discharged or 

released from active duty in the U.S. Armed Forces during the past year.

5 Check here if you are a veteran entitled to compensation for a service-connected disability and you were unemployed for a 

period or periods totaling at least 6 months during 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

• 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.

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.

Job applicant’s signature ▶ Date

For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 22851L Form 8850 (Rev. 1-2013)
Form 8850 (Rev. 1-2013) Page 2

For Employer’s Use Only

Employer’s name Telephone no. EIN ▶

Street address

City or town, state, and ZIP code

Person to contact, if different from above Telephone no.

Street address

City or town, state, and ZIP code

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) . . . . . . . . . . . . . . ▶

Date applicant:

Gave 

information

Was 

offered job

Was 

hired

Started 

job

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.

Employer’s signature ▶ Title Date

Privacy Act and 

Paperwork Reduction 

Act Notice

Section references are to the Internal 

Revenue Code.

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

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.

The time needed to complete and file 

this form will vary depending on 

individual circumstances. The estimated 

average time is:

Recordkeeping . . 6 hr., 27 min.

Learning about the law 

or the form . . . . . . . 30 min.

Preparing and sending this form 

to the SWA . . . . . . . 37 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:M:S, 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.

Form 8850 (Rev. 1-2013)