A Family Assistance Program

Form ****

(Rev. March ****)

Department of the Treasury

Internal Revenue Service

Pre-Screening Notice and Certification Request for the Work Opportunity Credit OMB No. 1545-1500

Ź Information about Form 8850 and its separate instructions is at www.irs.gov/form8850. Your Name Street adress where you live City or town, state, and ZIP code Social security number Ź BBBBBBBBBBBBBBBBBBBBBBBBB County Telephone number If you are under age 40, enter your date of birth (month, day, year) Job applicant: Fill in the lines below and check any boxes that apply. Complete only this side. BABA NDIATH ***-**-****

3717 KIMBERLY WEST DR

COLUMBUS, OHIO, 43232

FRANKLIN 614-***-****

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 Ź

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

BABA NDIATH - Electronically Signed,

05/21/2025 04:58:35 PM (ET) 05/21/2025

180139387, NDIATH, 2600, CINTAS CORP

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Check here if you received a conditional certification from the state workforce agency (SWA) or a participating local agency for the work opportunity credit.

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

(foodstamps) 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.

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. 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. 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. 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 timethose payments could be made.

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.

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 ŹBBBBBBBBBBBBBBBBBBBBBBBBBBBB Title Date Form 8850 (Rev. 3-2016)

Employer s name Telephone no. EIN Ź BBBBBBBBBBBBBBBBB 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) . . . . . . . . . . Ź Date applicant:

Gave

information

For Employer s Use Only

Was

offered job

Was

hired

Started

05/21/2025 05/21/2025 05/21/2025 job _05/ 21/__2025 DELOITTE TAX LLP, NICOLAS AVILA 888-***-****

2200 ROSS AVENUE SUITE 1600

DALLAS, TEXAS, 75201-6778

Form 8850 (Rev. 3-2016)

180139387, NDIATH, 2600, CINTAS CORP

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.

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