Service Security
Resume:
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.
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 a Date
For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 22851L Form 8850 (Rev. 3-2016) 16819 N 42ND AVE
PHOENIX, AZ 85053
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Darkenya Burris
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99 Holding Cents Only Stores, Inc. FADV EMID: 177985661
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