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.

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● 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 and Welfare-to-Work Credits

Form 8850 (Rev. 10-02)

(Rev. October 2002)

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 25, 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 or the Department of Veterans Affairs.

● I am at least age 18 but not age 25 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 and during the last 6 months I

was a member of a low-income family.

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.

Welfare-to-Work Credit

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

● Received TANF payments for at least the last 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 within the last 2 years, 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.

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Check here if you received a conditional certification from the SESA or a participating local agency for the

welfare-to-work credit.

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All Applicants
Form 8850 (Rev. 10-02) 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 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 on page 1, I believe the individual is a member of a

targeted group or a long-term family assistance recipient. I hereby request a certification that the individual is a member of a targeted group or a long-term family

assistance recipient.

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)(12) 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 and long-term family

assistance recipients 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 or a long-term family

assistance recipient. This form may also

be given to the Internal Revenue Service

The time needed to complete and file

this form will vary depending on

individual circumstances. The estimated

average time is:

Recordkeeping 2 hr., 46 min.

Learning about the law

or the form 36 min.

Preparing and sending this form

to the SESA 36 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 in

the separate instructions.

Section references are to the Internal

Revenue Code.

Form 8850 (Rev. 10-02)

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. In addition,

we may disclose this information to

Federal, state, or local agencies that

investigate or respond to acts or threats

of terrorism or participate in intelligence

or counterintelligence activities

concerning 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.