Tax Credit Screening

Our company participates in the Work Opportunity Tax Credit Program. Your responses to the following questions will be confidential and used only to assist us in complying with the requirements of this program. Your answers will not affect your employment or any benefits you may be receiving. This interview takes about 3 to 4 minutes to complete. Thank you!

First Name	*
Last Name	*
Address	*
City	*
State	*	Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
ZIP Code	*
Phone #	*
SSN #	*	(dashes added automatically)
Birth Date	*	MM/DD/YYYY
Job Title	*
Hourly Rate $	*	$
Start Date		MM/DD/YYYY
Please read each statement below and check YES to any statement that applies to you:   1. Have you worked for this employer before?   Yes No 2. Have you, or any immediate member of your family, EVER received Temporary Assistance to Needy Families  (TANF, WELFARE)?   Yes No 3. Have you, or a member of your family, received Supplemental Nutrition Assistance Program (SNAP) benefits (FOOD STAMPS) ANYTIME over the last 6 months?   Yes No 4. Have you been unemployed for the last 6 months AND received unemployment compensation at ANY TIME?   Yes No 5. I personally received Supplemental Security Income (SSI) or (SSDI) Supplemental Security Disability Income anytime during the last 2 months.   Yes No 6. I participated in a rehab program approved by the state, the Ticket to Work program, or the Department of Veterans Affairs.   Yes No 7. I am a Veteran of the United States Armed Forces.   Yes No 8. I am a Veteran who received Supplemental Nutrition Assistance Program (SNAP) benefits (FOOD STAMPS) ANYTIME over the last 6 months.   Yes No 9. I am a Veteran who was unemployed for more than 4 weeks, but less than 6 months, during the past year.   Yes No 10. I am a Veteran who was unemployed for more than 6 months during the past year.   Yes No 11. I am a Veteran discharged from active duty within the last 12 months and entitled to compensation for a service connected disability.   Yes No 12. I am a Veteran receiving compensation for a service connected disability who was unemployed for at least 6 months during the last 12 months.   Yes No 13. During the last 12 months, I was convicted of a felony or released from prison for a felony.   Yes No   < CHECK BOX I agree that I am voluntarily providing the information on this form and it is not a condition of employment. My signature authorizes the Department of Veterans Affairs, Department of Health and Human Services, Social Security Adminstration, and other Federal state, and local governments agencies to release information to verify my eligibility under the laws of the Work Opportunity Tax Credit. Under penalties of perjury, I declare that I provided the information on this form on or before the day employment was offered and that the information I have furnished is, to the best of my knowledge, true, correct, and complete. Electroncially sign Form 8850 by clicking Submit below. Please answer this question.

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