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Candidate's Name  (PSN)Applicant Name:Kroger Family of Companies is participating in the Work Opportunity Tax Credit (WOTC) program. This program is designed by the federal government to help companies with federal incentives for hiring and retaining individuals from certain targeted groups into the workforce.Your preliminary response to the IRS Form Street Address  questions below will help determine if Kroger Family of Companies qualifies for this program. Any information you provide will be kept confidential and will not negatively affect your job, wages, or taxes. Thank you in advance for your time and participation. In order to determine if this tax credit is available, if you are selected to interview, please advise (at your discretion) the company if any of the statements below apply to you.I received a conditional certification from the state workforce agency (SWA) or a participating local agency for the work opportunity credit.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 Veteran Affairs.I am at least age 18 but not age 40 or older and I am a member of a family that:Received SNAP benefits (food stamps) for the past 6 months, orReceived SNAP benefits (food stamps) for at least 3 of the past 5 months but is no longer eligible to receive them.I received supplement 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.I am a veteran and was unemployed for a period or periods totaling at least 6 months during the past year.I am a veteran entitled to compensation for a service-connected disability and I was discharged or released from active duty in the U.S. Armed Forces during the past year.I am a veteran entitled to compensation for a service-connected disability and I was unemployed for a period or periods totaling at least 6 months during the past year.I am a member of a family that:Received TANF payments for at least the past 18 months, orReceived 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, orStopped being eligible for TANF payments during the past 2 years because federal or state law limited the maximum time those payments could be made.I have been unemployed at least 27 consecutive weeks and for all or part of that period I received unemployment compensation.