Federal Free Printable Form 8850 (Rev. March 2016) for 2017 Federal Pre-Screening Notice and Certification Request for the Work Opportunity Credit

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Pre-Screening Notice and Certification Request for the Work Opportunity Credit
Form 8850 (Rev. March 2016)

8850 Pre-Screening Notice and Certification Request for the Work Opportunity Credit Form (Rev. March 2016) Department of the Treasury Internal Revenue Service ▶ OMB No. 1545-1500 Information about Form 8850 and its separate instructions is at www.irs.gov/form8850. 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. 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. Date Job applicant’s signature ▶ For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 22851L Form 8850 (Rev. 3-2016) Page 2 Form 8850 (Rev. 3-2016) 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 ▶ 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 Title 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. Date 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 . . . . . . . 24 min. Preparing and sending this form to the SWA . . . . . . . 31 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 send us comments from www.irs.gov/formspubs. Click on “More Information” and then on “Give us feedback.” Or you can send your comments to: Internal Revenue Service Tax Forms and Publications 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. 3-2016)
Extracted from PDF file 2016-federal-form-8850.pdf, last modified March 2016

More about the Federal Form 8850 Other Tax Credit TY 2016

We last updated the Pre-Screening Notice and Certification Request for the Work Opportunity Credit in May 2017, so this is the latest version of Form 8850, fully updated for tax year 2016. You can download or print current or past-year PDFs of Form 8850 directly from TaxFormFinder. You can print other Federal tax forms here.

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Form Sources:

The Internal Revenue Service usually releases income tax forms for the current tax year between October and January, although changes to some forms can come even later. We last updated Federal Form 8850 from the Internal Revenue Service in May 2017.

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Form 8850 is a Federal Other form. States often have dozens of even hundreds of various tax credits, which, unlike deductions, provide a dollar-for-dollar reduction of tax liability. Some common tax credits apply to many taxpayers, while others only apply to extremely specific situations. In most cases, you will have to provide evidence to show that you are eligible for the tax credit, and calculate the amount of the credit to which you are entitled.

Historical Past-Year Versions of Federal Form 8850

We have a total of five past-year versions of Form 8850 in the TaxFormFinder archives, including for the previous tax year. Download past year versions of this tax form as PDFs here:


2016 Form 8850

Form 8850 (Rev. March 2016)

Pre-Screening Notice and Certification Request for the Work Opportunity Credit 2015 Form 8850

Form 8850 (Rev. March 2015)

Pre-Screening Notice and Certification Request for the Work Opportunity Credit 2013 Form 8850

Form 8850 (Rev. January 2013)

Pre-Screening Notice and Certification Request for the Work Opportunity Credit 2012 Form 8850

Form 8850 (Rev. January 2012)

Pre-Screening Notice and Certification Request for the Work Opportunity Credit 2011 Form 8850

Form 8850 (Rev. January 2012)


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