www.irs.gov/form****. OMB No. ****-****

Job appapply. Complete only this side. Your name Social security

City or town, stateenter your date of birth (month, day, year) 1 Check here if you received a conditional certififor 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.

Job applicant’s signature Date

For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 22851L Form 8850 (Rev. 3-2016) Form 8850 (Rev. 3-2016) Page 2

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 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. 3-2016)

Contact this candidate