Form (Rev. March **** ****)

Department of the Treasury

Internal Revenue Service

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

a 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 a

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 a Date

For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 22851L Form 8850 (Rev. 3-2015) Form 8850 (Rev. 3-2015) Page 2

For Employer’s Use Only

Employer’s name Telephone no. EIN a

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) a 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 a 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 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. 3-2015)

Employee Risk Management Co., Inc 361-***-**** 74-272****-**** Corona Suite 99

Corpus Christi, TX 78411

Laura Escobar 361-***-****

1

Individual Characteristics Form (ICF)

Work Opportunity Tax Credit

1. Control No. (For Agency use only)

APPLICANT INFORMATION

(See instructions on reverse)

2. Date Received (For Agency Use only)

EMPLOYER INFORMATION

3. Employer Name

4. Employer Address and Telephone

5. Employer Federal ID Number (EIN)

APPLICANT INFORMATION

6. Applicant Name (Last, First, MI)

7. Social Security Number

8. Have you worked for this employer

before? Yes No

If YES, enter last date of

employment:

APPLICANT CHARACTERISTICS FOR WOTC TARGET GROUP CERTIFICATION 9. Employment Start Date

10. Starting Wage 11. Position

12. Are you at least age 16, but under age 40? Yes No If YES, enter your date of birth 13. Are you a Veteran of the U.S. Armed Forces? Yes No If NO, go to Box 14.

If YES, are you a member of a family that received Supplemental Nutrition Assistance Program (SNAP) benefits (Food Stamps) for at least 3 months during the 15 months before you were hired? Yes No

If YES, enter name of primary recipient and city and state where benefits were received . OR, are you a veteran entitled to compensation for a service-connected disability? Yes No If YES, were you discharged or released from active duty within a year before you were hired? Yes No OR, were you unemployed for a combined period of at least 6 months (whether or not consecutive) during the year before you were hired? Yes No 14. Are you a member of a family that received Supplemental Nutrition Assistance Program

(SNAP) (formerly Food Stamps) benefits for the 6 months before you were hired? Yes No OR, received SNAP benefits for at least a 3-month period within the last 5 months But you are no longer receiving them? Yes No If YES to either question, enter name of primary recipient and city And state where benefits were received . 15. Were you referred to an employer by a Vocational Rehabilitation Agency approved by a State? Yes No

OR, by an Employment Network under the Ticket to Work Program? Yes No OR, by the Department of Veterans Affairs? Yes No 16. Are you a member of a family that received TANF assistance for at least the last 18 months U.S. Department Labor

Employment and Training Administration

OMB Control No. 1205-0371

Expiration Date: January 31, 2020

2

before you were hired? Yes No

OR, are you a member of a family that received TANF benefits for any 18 months beginning after August 5, 1997, and the earliest 18-month period beginning after August 5, 1997, ended within 2 years before you were hired? Yes No OR, did your family stop being eligible for TANF assistance within 2 years before you were hired because a Federal or state law limited the maximum time those payments could be made? Yes No If NO, are you a member of a family that received TANF assistance for any 9 months during the 18-month period before you were hired? Yes No If YES, to any question, enter name of primary recipient and the city and state where benefits were received . 17. Were you convicted of a felony or released from prison after a felony conviction during the year before you were hired? Yes No

If YES, enter date of conviction and date of release . Was this a Federal or a State conviction ? (Check one) 18. Do you live in an Empowerment Zone or Rural Renewal County (RRC)? Yes__ No __ 19. Do you live in an Empowerment Zone and are at least age 16, but not yet 18, on Yes __ No __ your hiring date?

20. Did you receive Supplemental Security Income (SSI) benefits for any month ending within 60 days before you were hired? Yes__ No__

21. Are you a veteran unemployed for a combined period of at least 6 months (whether or not consecutive) during the year before you were hired? Yes__ No__ 22. Are you a veteran unemployed for a combined period of at least 4 weeks but less than 6 months (whether or not consecutive) during the year before you were hired? Yes__ No__ 23. Are you an individual who is or was in a period of unemployment that is at least 27 consecutive weeks and for all or part of that period you received unemployment compensation? Yes__ No__ If YES, what state did you receive unemployment compensation in?

(Enter state where UI compensation was received)

24. Sources used to document eligibility: (Employers/Consultants: List all documentation provided or forthcoming. For SWA Staff: List all documentation used in determining target group eligibility and enter your initials and date when the determination was made.

I certify that this information is true and correct to the best of my knowledge. I understand that the information above may be subject to verification.

25(a). Signature: (See instructions in Box 25.(b) for who signs this signature block)

25.(b) Indicate with a 9 mark who

signed this form:

Employer, Consultant, SWA,

Participating Agency, Applicant, or

Parent/Guardian (if applicant is a

minor)

26. Date:

ETA Form 9061 (Rev. November 2016)

BRINKS PAY CARD ELECTION FORM

Brink’s Money™ Program (the “Program”) – 1 Time $2.00 Fee With the Program, your wages will be deposited in your Brink’s Money Account, which is maintained in a pooled custodial account at the bank that is issuing/sponsoring the Program (“Bank”) and which is insured by the FDIC up to the limits permitted by law. Every employee is eligible for the Program. There is no application and no credit approval process (but we may ask you for information and/or documents that will allow us to identify you, such as your date of birth, social security number and driver’s license). The Program allows you to use either or both of the following options to access your Brink’s Money Account:

1. The Skylight Check. The Skylight Check is a self-issued paycheck that can be completed each payday. You’ll receive a supply of Skylight Checks for free. The Skylight Check is completed by phone wherever you may be. The Skylight Check can be cashed for free at all branch locations of the bank that issues the Skylight Check (please refer to the front of the Skylight Check for the name of the bank that issues the Skylight check) and Skylight’s check cashing partners. 2. The Brink’s Money Card. With your Brink’s Money Card, you can make purchases at stores or get cash through ATM withdrawals. You can also use your Brink’s Money Card to access 100% of your wages, down to the penny, without any fee, at any MasterCard member bank (look for a bank branch with the MasterCard logo). You can check your balance for free via IVRU, online or text (your carrier’s standard rates for text messages may apply). Most card transactions are free but there are transaction fees for certain transactions. All of the transaction fees are listed on the Fee Schedule in your Brink’s Money Instant Issue Pack. Brink’s Money™ Program (Replacement Card) – 1st Occurrence $10.00 Fee Brink’s Money™ Program (Replacement Card) – 2nd Occurrence $15.00 Fee Brink’s Money™ Program (Replacement Card) – 3rd Occurrence $20.00 Fee NOTE:

If you select this option, you

understand that you can

access all of your pay each

payday for free by

completing the Skylight

Check. In addition, you

acknowledge that you may

voluntarily use the Brink’s

Money Card if you so choose.

Further, you acknowledge

that you have been provided

with a copy of and an

opportunity to review

disclosures relating to the

Program, which include, at a

minimum, the Cardholder

Agreement, Fee Schedule and

Privacy Policy relating to the

Program.

By selecting either of the options on this Pay Election Form and signing hereunder, I authorize the Employer to charge the appropriate fees and to send credit entries (and appropriate debit and adjustment entries), electronically or by any other commercially accepted method, to the account that I have provided above or to the Brink’s Money Account, as applicable (each an “Account”) both during employment and at termination. This authorizes the financial institution holding the Account to post all such entries. Further, I understand that I have the right to change the method of payment that I have elected on this form. If I do desire to change my method of payment, then I will notify the Employer and execute a new Pay Election Form setting forth my new election. I understand that if I desire to change the method of payment from the Program to any other method of payment, I should obtain the full balance in my Brinks Money Account and then close the Brinks Money Account prior to requesting such change. This authorization will be in effect until the Employer receives a written notice from myself to change my pay election and has a reasonable opportunity to act on it, which shall be no longer than the time permitted by applicable law, if any. Finally, I understand that if I select the Program and continue to use the Program following the termination of my employment with the Employer, certain terms, conditions and fees relating to the Program may change, pursuant to the terms of the Cardholder Agreement. Signature Date

Printed Name Last Four Numbers of SSN

AUTHORIZATION AGREEMENT

FOR

DIRECT DEPOSITS (ACH CREDITS)

I (we) hereby authorize hereinafter called COMPANY, to initiate credit entries and to initiate, if necessary, debit entries and adjustments for any credit entries in error, to my (our) account indicated below at the depository financial institution named below, hereinafter called DEPOSITORY, ant to credit and/or debit the same to such account. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law. You must verify your electronic account information with your Financial Institution and attach a voided check or an account verification form from you Financial Institution. Financial Institution: City State Zip Code Checking or Savings Routing Number Account Number This authorization is to remain in full force and effect until COMPANY has received WRITTEN notification from me

(or either of us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it.

Name(s) Social Security # Signature Date

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