Form 8850

(Rev. March 2016)

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:
    1. Received SNAP benefits (food stamps) for the past 6 months; or
    2. 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:
  1. Received TANF payments for at least the past 18 months; or
  2. 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
  3. 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.
7
Check here if you are in a period of unemployment that is at least 27 consecutive weeks and for all or part of that period you received unemployment compensation.
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
Signature Date:
For Privacy Act and Paperwork Reduction Act Notice, see page 2.
Form 8850 (Rev. 3-2016)
Cat. No. 22851L