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www.irs.gov/form8850. OMB No. 1545-1500Job appapply. Complete only this side. Your name Social securityCity 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 Street Address  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 Street Address  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.SignatureAll Applicants Must SignUnder 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 applicants signature DateFor Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 22851L Form 8850 (Rev. 3-2016) Form 8850 (Rev. 3-2016) Page 2For Employers Use OnlyEmployers name Telephone no. EINStreet addressCity or town, state, and ZIP codePerson to contact, if different from above Telephone no. Street addressCity or town, state, and ZIP codeIf, based on the individuals 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:GaveinformationWasoffered jobWashiredStartedjobUnder 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. Employers signature Title DatePrivacy Act andPaperwork ReductionAct NoticeSection references are to the InternalRevenue Code.Section 51(d)(13) permits a prospectiveemployer to request the applicant tocomplete this form and give it to theprospective employer. The informationwill be used by the employer tocomplete the employers federal taxreturn. Completion of this form isvoluntary and may assist members oftargeted groups in securing employment.Routine uses of this form include givingit to the state workforce agency (SWA),which will contact appropriate sourcesto confirm that the applicant is amember of a targeted group. This formmay also be given to the InternalRevenue Service for administration ofthe Internal Revenue laws, to theDepartment of Justice for civil andcriminal litigation, to the Department ofLabor for oversight of the certificationsperformed by the SWA, and to cities,states, and the District of Columbia foruse in administering their tax laws. Wemay also disclose this information toother countries under a tax treaty, tofederal and state agencies to enforcefederal nontax criminal laws, or tofederal law enforcement and intelligenceagencies to combat terrorism.You are not required to provide theinformation requested on a form that issubject to the Paperwork Reduction Actunless the form displays a valid OMBcontrol number. Books or recordsrelating to a form or its instructions mustbe retained as long as their contentsmay become material in theadministration of any Internal Revenuelaw. Generally, tax returns and returninformation are confidential, as requiredby section 6103.The time needed to complete and filethis form will vary depending onindividual circumstances. The estimatedaverage time is:Recordkeeping . . 6 hr., 27 min.Learning about the lawor the form . . . . . . . 24 min.Preparing and sending this formto the SWA . . . . . . . 31 min.If you have comments concerning theaccuracy of these time estimates orsuggestions for making this formsimpler, we would be happy to hear fromyou. You can send us comments fromwww.irs.gov/formspubs. Click on MoreInformation and then on Give usfeedback. Or you can send yourcomments to:Internal Revenue ServiceTax Forms and Publications1111 Constitution Ave. NW, IR-6526Washington, DC 20224Do not send this form to this address.Instead, see When and Where To File inthe separate instructions.Form 8850 (Rev. 3-2016)