Representative Information

WORK OPPORTUNITY TAX CREDIT PACKAGE

EMPLOYEE INSTRUCTIONS

Thank you for completing the tax credit screening portion of your application process. We have determined that your prospective new employer may qualify for the Work Opportunity Tax Credit program. There will be several tax credit forms that will be signed electronically after you create your password which will include the 8850 and authorization for release form.

We appreciate your assistance.

AUTHORIZATION FOR DISCLOSURE OF INFORMATION

I hereby authorize my employer or employer representative to obtain information from my records to determine my eligibility for the Work Opportunity Tax Credit Program. I also authorize the appropriate agency to release the requested information from my records to my employer or employer representative; including Social Security Administration for a TPQY printout.

Employee Name: SSN:

Employee Signature: Date:

Christopher Carver

KVA

* 6IZ 1EVGL SVQ

4VI 7GVIIRMRK 2SXMGI ERH 'IVXMJMGEXMSR 6IUYIWX JSV XLI ;SVO 3TTSVXYRMX] 'VIHMX

-RJSVQEXMSR EFSYX *SVQ ERH MXW WITEVEXI MRWXVYGXMSRW MW EX 31& 2S

.SF ETTPMGERX *MPP MR XLI PMRIW FIPS[ ERH GLIGO ER] FS\IW XLEX ETTP SQTPIXI SRP] XLMW WMHI

=SYV REQI 7SGMEP WIGYVMX] RYQFIV

7XVIIX EHHVIWW [LIVI ]SY PMZI

'MX] SV XS[R WXEXI ERH >-4 GSHI

'SYRX] 8IPITLSRI RYQFIV

-J ]SY EVI YRHIV EKI IRXIV ]SYV HEXI SJ FMVXL QSRXL HE IEV

'LIGO LIVI MJ ]SY VIGIMZIH E GSRHMXMSREP GIVXMJMGEXMSR JVSQ XLI WXEXI [SVOJSVGI EKIRG] 7;%

SV E TEVXMGMTEXMRK PSGEP EKIRG] JSV XLI [SVO STTSVXYRMX] GVIHMX

'LIGO LIVI MJ ER] SJ XLI JSPPS[MRK WXEXIQIRXW ETTP] XS ]SY y EQ E QIQFIV SJ E JEQMP] XLEX LEW VIGIMZIH EWWMWXERGI JVSQ 8IQTSVEV] %WWMWXERGI JSV 2IIH] *EQMPMIW 8%2*

JSV ER] QSRXLW HYVMRK XLI TEWX QSRXLW

y EQ E ZIXIVER ERH E QIQFIV SJ E JEQMP] XLEX VIGIMZIH 7YTTPIQIRXEP 2YXVMXMSR %WWMWXERGI 4VSKVEQ 72%4

FIRIJMXW JSSH WXEQTW

JSV EX PIEWX E QSRXL TIVMSH HYVMRK XLI TEWX QSRXLW y EW VIJIVVIH LIVI F] E VILEFMPMXEXMSR EKIRG] ETTVSZIH F] XLI WXEXI ER IQTPS]QIRX RIX[SVO YRHIV XLI 8MGOIX XS ;SVO TVSKVEQ SV XLI (ITEVXQIRX SJ :IXIVERW %JJEMVW

y EQ EX PIEWX EKI FYX RSX EKI SV SPHIV ERH - EQ E QIQFIV SJ E JEQMP] XLEX E 6IGIMZIH 72%4 FIRIJMXW JSSH WXEQTW

JSV XLI TEWX QSRXLW SV F 6IGIMZIH 72%4 FIRIJMXW JSSH WXEQTW

JSV EX PIEWX SJ XLI TEWX QSRXLW FYX MW RS PSRKIV IPMKMFPI XS VIGIMZI XLIQ y (YVMRK XLI TEWX ]IEV EW GSRZMGXIH SJ E JIPSR] SV VIPIEWIH JVSQ TVMWSR JSV E JIPSR] y VIGIMZIH WYTTPIQIRXEP WIGYVMX] MRGSQI 77-

FIRIJMXW JSV ER] QSRXL IRHMRK HYVMRK XLI TEWX HE]W y EQ E ZIXIVER ERH EW YRIQTPS]IH JSV E TIVMSH SV TIVMSHW XSXEPMRK EX PIEWX IIOW FYX PIWW XLER QSRXLW HYVMRK XLI TEWX ]IEV

'LIGO LIVI MJ ]SY EVI E ZIXIVER ERH ]SY [IVI YRIQTPS]IH JSV E TIVMSH SV TIVMSHW XSXEPMRK EX PIEWX QSRXLW HYVMRK XLI TEWX

]IEV

'LIGO LIVI MJ ]SY EVI E ZIXIVER IRXMXPIH XS GSQTIRWEXMSR JSV E WIVZMGI GSRRIGXIH HMWEFMPMX] ERH ]SY [IVI HMWGLEVKIH SV VIPIEWIH JVSQ EGXMZI HYX] MR XLI 9 7 %VQIH *SVGIW HYVMRK XLI TEWX ]IEV

'LIGO LIVI MJ ]SY EVI E ZIXIVER IRXMXPIH XS GSQTIRWEXMSR JSV E WIVZMGI GSRRIGXIH HMWEFMPMX] ERH ]SY [IVI YRIQTPS]IH JSV E TIVMSH SV TIVMSHW XSXEPMRK EX PIEWX QSRXLW HYVMRK XLI TEWX ]IEV

'LIGO LIVI MJ ]SY EVI E QIQFIV SJ E JEQMP] XLEX y 6IGIMZIH 8%2* TE]QIRXW JSV EX PIEWX XLI TEWX QSRXLW SV y 6IGIMZIH 8%2* TE]QIRXW JSV ER QSRXLW FIKMRRMRK EJXIV %YKYWX ERH XLI IEVPMIWX QSRXL TIVMSH FIKMRRMRK EJXIV %YKYWX IRHIH HYVMRK XLI TEWX IEVW SV y 7XSTTIH FIMRK IPMKMFPI JSV 8%2* TE]QIRXW HYVMRK XLI TEWX IEVW FIGEYWI JIHIVEP SV WXEXI PE[ PMQMXIH XLI QE\MQYQ XMQI XLSWI TE]QIRXW GSYPH FI QEHI

'LIGO LIVI MJ ]SY EVI MR E TIVMSH SJ YRIQTPS]QIRX XLEX MW EX PIEWX GSRWIGYXMZI [IIOW ERH JSV EPP SV TEVX SJ XLEX TIVMSH

]SY VIGIMZIH YRIQTPS]QIRX GSQTIRWEXMSR

7MKREXYVI{%PP %TTPMGERXW 1YWX 7MKR

9RHIV TIREPXMIW SJ TIVNYV HIGPEVI XLEX - KEZI XLI EFSZI MRJSVQEXMSR XS XLI IQTPS]IV SR SV FIJSVI XLI HE EW SJJIVIH E NSF ERH MX MW XS XLI FIWX SJ Q] ORS[PIHKI XVYI GSVVIGX ERH GSQTPIXI

.SF ETTPMGERXvW WMKREXYVI (EXI

*SV 4VMZEG] %GX ERH 4ETIV[SVO 6IHYGXMSR %GX 2SXMGI WII TEKI 'EX 2S 0 *SVQ 6IZ Christopher Carver

Chatsworth GA 30705

4752

1178 hwy 225 s

X

1/30/2018

X

12/28/1981

Contact this candidate