TEGL_4_12_Att6.pdf

ETA Advisory File Text

Form Rev. January 2012 8850 Department of the Treasury Internal Revenue Service Pre-Screening Notice and Certification Request for the Work Opportunity Credit a See separate instructions. OMB No. 1545-1500 Job applicant Fill in the lines below and check any boxes that apply. C omplete only this side. Your nameSocial security number a Street address where you live City or town state and ZIP code CountyTelephone 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 wo rkforce 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 Tempor ary 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 sta te 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 aReceived SNAP benefits food stamps for the past 6 months or b Received SNAP benefits food stamps for at least 3 of the past 5 mont hs 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 m onth ending during the past 60 days. I am a veteran and I was unemployed for a period or periods totali ng at least 4 weeks but less than 6 months during thepast 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-c onnected 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-c onnected disability and you were unemployed for a period or periods totaling at least 6 months during the past year. 6Check 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 be cause federal or state law limited the maximum timethose payments could be made. 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. 22851LForm 8850 Rev. 1-2012 Form 8850 Rev. 1-2012 Page 2 For Employer s Use Only Employer s nameTelephone no.EIN a Street address City or town state and ZIP code Person to contact if different from aboveTelephone 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 me mber of group 4 or 6 as described under Members of Targeted Groups in the separate instructions enter that group number 4 or 6 .............. a Date applicant Gave Was Was Started informationoffered jobhiredjob Under penalties of perjury I declare that the applicant provided the in formation 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 corr ect 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 a TitleDate criminal litigation to the Department of The time needed to complete and file Privacy Act and Labor for oversight of the certifications this form will vary depending on Paperwork Reduction performed by the SWA and to cities individual circumstances. The estimated states and the District of Columbia for average time is Act Notice use in administering their tax laws. We Recordkeeping .. 6 hr. 27 min. Section references are to the Internal may also disclose this information to Revenue Code.other countries under a tax treaty to Learning about the law federal and state agencies to enforce or the form ....... 30 min. Section 51 d 13 permits a prospective federal nontax criminal laws or to employer to request the applicant to Preparing and sending this form federal law enforcement and intelligence complete this form and give it to the to the SWA ....... 37 min. agencies to combat terrorism. prospective employer. The information If you have comments concerning the will be used by the employer to You are not required to provide the accuracy of these time estimates or complete the employer s federal tax information requested on a form that is suggestions for making this form return. Completion of this form is subject to the Paperwork Reduction Act simpler we would be happy to hear from voluntary and may assist members of unless the form displays a valid OMB you. You can write to the Internal targeted groups in securing employment. control number. Books or records Revenue Service Tax Products Routine uses of this form include giving relating to a form or its instructions must Coordinating Committee it to the state workforce agency SWA be retained as long as their contents SE W CAR MP T M S 1111 Constitution which will contact appropriate sources may become material in the Ave. NW IR-6526 Washington DC to confirm that the applicant is a administration of any Internal Revenue 20224. member of a targeted group. This form law. Generally tax returns and return may also be given to the Internal information are confidential as required Do not send this form to this address. Revenue Service for administration of by section 6103. Instead see When and Where To File in the Internal Revenue laws to the the separate instructions. Department of Justice for civil and Form 8850 Rev. 1-2012 Instructions for Form 8850 Department of the Treasury Internal Revenue Service Rev. January 2012 Pre-Screening Notice and Certification Request for the Work Opportunity Credit General Instructions Section references are to the Internal Revenue Code unless otherwise noted. What s New For certain veterans who begin work after November 21 2011 and before 2013 the qualified veteran targeted group has been expanded to cover veterans who were unemployed for at least 4 weeks during the 1-year period ending on the hiring date. The Hurricane Katrina employee targeted group expired for individuals hired after August 27 2009. The unemployed veteran and disconnected youth targeted groups expired for individuals hired after 2010. The empowerment zone designations were extended until the end of 2011. The renewal community designations expired at the end of 2009. Some states may be equipped to accept a faxed copy of Form 8850 and additional states are equipped to receive Form 8850 electronically. The IRS has created a page on IRS.gov for information about Form 8850 and its instructions at www.irs.gov form8850. Information about any future developments affecting Form 8850 such as legislation enacted after we release it will be posted on that page. Purpose of Form Employers use Form 8850 to pre-screen and to make a written request to their state workforce agency SWA to certify an individual as a member of a targeted group for purposes of qualifying for the work opportunity credit. Submitting Form 8850 to the SWA is but one step in the process of qualifying for the work opportunity credit. The state work opportunity tax credit WOTC coordinator for the SWA must certify the job applicant is a member of a targeted group. After starting work the employee must meet the minimum number-of-hours-worked requirement for the work opportunity credit. Generally an employer elects to take the credit by filing Form 5884 Work Opportunity Credit. However a tax-exempt organization that hires a qualified veteran should report the work opportunity credit on Form 5884-C Work Opportunity Credit for Qualified Tax-Exempt Organizations Hiring Qualified Veterans. Who Should Complete and Sign the Form The job applicant gives information to the employer on or before the day a job offer is made. This information is entered on Form 8850. Based on the applicant s information the employer determines whether or not he or she believes the applicant is a member of a targeted group as defined under Members of Targeted Groups . If the employer believes the applicant is a member of a targeted group the employer completes the rest of the form no later than the day the job offer is made. Both the job applicant and the employer must sign Form 8850 no later than the date for submitting the form to the SWA. Instructions for Employer When and Where To File Do not file Form 8850 with the Internal Revenue Service. Instead file it with your SWA no later than the 28th day after the job applicant begins work for you by June 19 2012 for all qualified veterans who begin work after November 21 2011 and before May 22 2012 . Although facsimile filing of Form 8850 is permitted not all states are equipped to accept a faxed copy of Form 8850. Contact your state WOTC coordinator as discussed below and see Notice 2012-13 for details. Notice 2012-13 is available at www.irs.gov pub irs-drop n-12-13.pdf. Although electronic filing of Form 8850 is permitted at the time these instructions were published only the following states are equipped to receive Form 8850 electronically Alabama Arizona Arkansas Colorado Florida Illinois Kansas Kentucky Minnesota New Jersey Ohio Pennsylvania and South Carolina. See Announcement 2002-44 and Notice 2012-13 for details. You can find Announcement 2002-44 on page 809 of Internal Revenue Bulletin 2002-17 at www.irs.gov pub irs-irbs irb02-17.pdf. To get the name address phone and fax numbers and email address of the WOTC coordinator for your state visit the Department of Labor Employment and Training Administration ETA website at www.doleta.gov business Incentives opptax. Never attach Form 8850 to a tax return or otherwise send it to the IRS regardless of the employee s CAUTION targeted group. Form 8850 should be filed with the SWA. Additional Requirements for Certification In addition to filing Form 8850 you must complete and send to your state WOTC coordinator either ETA Form 9062 Conditional Certification Form if the job applicant received this form from a participating agency e.g. the Jobs Corps or ETA Form 9061 Individual Characteristics Form if the job applicant did not receive a conditional certification. You can get ETA Form 9061 from your local public employment service office or you can download it from the ETA website at www.doleta.gov business Incentives opptax. Recordkeeping Keep copies of Forms 8850 any transmittal letters that you submit to your state WOTC coordinator and certification letters you receive from your WOTC coordinator as long as they may be needed for the administration of the provisions relating to the work opportunity credit. Records that support the credit usually must be kept for 3 years from the date any income tax return claiming the credit is due or filed whichever is later. Cat. No. 24833J Feb 09 2012 Members of Targeted Groups A job applicant may be certified as a member of a targeted group if he or she is described in one of the following groups.1.Qualified IV-A recipient. An individual who is a member of a family receiving assistance under a state plan approved under part A of title IV of the Social Security Act relating to Temporary Assistance for Needy Families TANF . The assistance must be received for any 9 months during the 18-month period ending on the hiring date. 2.Qualified veteran. A veteran who is any of the following. A member of a family receiving assistance under the Supplemental Nutrition Assistance Program SNAP food stamps for at least a 3-month period during the 15-month period ending on the hiring date. Unemployed for a period or periods totaling at least 4 weeks whether or not consecutive but less than 6 months in the 1-year period ending on the hiring date. Unemployed for a period or periods totaling at least 6 months whether or not consecutive in the 1-year period ending on the hiring date. Entitled to compensation for a service-connected disability and is hired not more than 1 year after being discharged or released from active duty in the U.S. Armed Forces. Entitled to compensation for a service-connected disability and was unemployed for a period or periods totaling at least 6 months whether or not consecutive in the 1-year period ending on the hiring date. Note.Requesting the information in box 4 or box 5 of Form 8850 is an exception to the Americans with Disabilities Act s prohibition on pre-offer disability-related inquiries. The purpose of this request is to support the hiring of certain disabled veterans which will entitle the employer to a larger work opportunity credit than the hiring of other targeted group members. To be considered a veteran the applicant must Have served on active duty not including training in the Armed Forces of the United States for more than 180 days or have been discharged or released from active duty for a service-connected disability and Not have a period of active duty not including training of more than 90 days that ended during the 60-day period ending on the hiring date. 3.Qualified ex-felon. An ex-felon who has been convicted of a felony under any federal or state law and is hired not more than 1 year after the conviction or release from prison for that felony. 4.Designated community resident. An individual who is at least age 18 but not yet age 40 on the hiring date and lives within an empowerment zone or rural renewal county defined later . 5.Vocational rehabilitation referral. An individual who has a physical or mental disability resulting in a substantial handicap to employment and who was referred to the employer upon completion of or while receiving rehabilitation services by a rehabilitation agency approved by the state an employment network under the Ticket to Work program or the Department of Veterans Affairs. 6.Summer youth employee. An individual who Performs services for the employer between May 1 and September 15 Is at least age 16 but not yet age 18 on the hiring date or if later on May 1 Has never worked for the employer before and Lives within an empowerment zone. 7.Recipient of SNAP benefits food stamps . An individual who Is at least age 18 but not yet age 40 on the hiring date and Is a member of a family that a. Has received SNAP benefits for the 6-month period ending on the hiring date orb. Is no longer eligible for such assistance under section 6 o of the Food Stamp Act of 1977 but the family received SNAP benefits for at least 3 months of the 5-month period ending on the hiring date. 8.SSI recipient. An individual who is receiving supplemental security income benefits under title XVI of the Social Security Act including benefits of the type described in section 1616 of the Social Security Act or section 212 of Public Law 93-66 for any month ending during the 60-day period ending on the hiring date.9.Long-term family assistance recipient. An individual who is a member of a family that Has received TANF payments for at least 18 consecutive months ending on the hiring date or Receives TANF payments for any 18 months whether or not consecutive 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 because federal or state law limits the maximum period such assistance is payable and the individual is hired not more than 2 years after such eligibility ended. Member of a Family With respect to the qualified IV-A recipient qualified veteran recipient of SNAP benefits food stamps and long-term family assistance recipient an individual whose family receives assistance for the requisite period meets the family assistance requirement of the applicable group if the individual is included on the grant and thus receives assistance for some portion of the specified period. Empowerment Zones The following paragraphs describe current designations of empowerment zones. The designations will generally remain in effect until the end of 2011. Urban areas.Parts of the following urban areas are empowerment zones. You can find out if your business or an employee s residence is located within an urban empowerment zone by using the EZ RC Address Locator at www.hud.gov crlocator or by calling 1-800-998-9999. Pulaski County AR Tucson AZ Fresno CA Los Angeles CA city and county Santa Ana CA New Haven CT Jacksonville FL Miami Dade County FL Chicago IL Gary Hammond East Chicago IN Boston MA Baltimore MD Detroit MI Minneapolis MN St. Louis MO East St. Louis IL Cumberland County NJ New York NY Syracuse NY Yonkers NY Cincinnati OH Cleveland OH Columbus OH Oklahoma City OK Philadelphia PA Camden NJ Columbia Sumter SC Knoxville TN El Paso TX San Antonio TX Norfolk Portsmouth VA Huntington WV Ironton OH -2- Washington DC.Under section 1400 parts of Washington DC are treated as an empowerment zone. This treatment will generally remain in effect until the end of 2011. For details use the EZ RC Address Locator at www. hud.gov crlocator or see Notice 98-57 on page 9 of Internal Revenue Bulletin 1998-47 at www.irs.gov pub irs-irbs irb98-47.pdf. Rural areas.Parts of the following rural areas are empowerment zones. You can find out if your business or an employee s residence is located within a rural empowerment zone by using the EZ RC Address Locator at www.hud.gov crlocator or by calling 1-800-998-9999. Desert Communities CA part of Riverside County Southwest Georgia United GA part of Crisp County and all of Dooly County Southernmost Illinois Delta IL parts of Alexander and Johnson Counties and all of Pulaski County Kentucky Highlands KY part of Wayne County and all of Clinton and Jackson Counties Aroostook County ME part of Aroostook County Mid-Delta MS parts of Bolivar Holmes Humphreys Leflore Sunflower and Washington Counties Griggs-Steele ND part of Griggs County and all of Steele County Oglala Sioux Tribe SD parts of Jackson and Bennett Counties and all of Shannon County Middle Rio Grande FUTURO Communities TX parts of Dimmit Maverick Uvalde and Zavala Counties Rio Grande Valley TX parts of Cameron Hidalgo Starr and Willacy Counties Rural Renewal Counties A rural renewal county is a county in a rural area that lost population during the 5-year periods 1990 through 1994 and 1995 through 1999. Rural renewal counties are listed below. Alabama.The counties of Butler Dallas Macon Perry Sumter and Wilcox. Alaska.The census areas of Aleutians West Wrangell-Petersburg and Yukon-Koyukuk. Arkansas.The counties of Arkansas Chicot Clay Desha Jackson Lafayette Lee Little River Monroe Nevada Ouachita Phillips Union and Woodruff. Colorado.The counties of Cheyenne Kiowa and San Juan. Georgia.The counties of Randolph and Stewart. Illinois.The counties of Alexander Edwards Franklin Gallatin Greene Hancock Hardin Jasper Knox McDonough Montgomery Pulaski Randolph Richland Scott Warren Wayne and White. Indiana.Perry County. Iowa.The counties of Adair Adams Appanoose Audubon Butler Calhoun Cass Cherokee Clay Clayton Emmet Floyd Franklin Fremont Hancock Humboldt Ida Keokuk Kossuth Montgomery Osceola Palo Alto Pocahontas Poweshiek Sac Taylor Union Wayne Winnebago and Worth. Kansas.The counties of Atchison Barber Barton Brown Clay Cloud Comanche Decatur Edwards Elk Ellsworth Gove Graham Greeley Greenwood Harper Hodgeman Jewell Kiowa Labette Lane Lincoln Marshall Mitchell Montgomery Ness Osborne Phillips Rawlins Republic Rooks Rush Russell Scott Sheridan Sherman Smith Stafford Trego Wallace Washington Wichita and Woodson. Kentucky.The counties of Bell Caldwell Floyd Harlan Hickman Leslie Letcher Pike and Union. Louisiana.The parishes of Bienville Claiborne Franklin Jackson Morehouse St. Mary Tensas Vernon and Webster.Maine. The counties of Aroostook and Piscataquis. Michigan.The counties of Gogebic Marquette and Ontonagon. Minnesota.The counties of Big Stone Chippewa Cottonwood Faribault Jackson Kittson Koochiching Lac Qui Parle Lincoln Marshall Martin Murray Norman Pipestone Red Lake Redwood Renville Stevens Traverse Wilkin and Yellow Medicine. Mississippi.The counties of Adams Coahoma Humphreys Montgomery Quitman Sharkey Tallahatchie and Washington. Missouri.The counties of Atchison Carroll Chariton Clark Holt Knox Mississippi New Madrid Pemiscot and Worth. Montana.The counties of Carter Daniels Dawson Deer Lodge Fallon Garfield Hill Liberty McCone Petroleum Phillips Powder River Prairie Richland Roosevelt Rosebud Sheridan Valley and Wibaux. Nebraska.The counties of Antelope Banner Boone Box Butte Boyd Burt Cedar Chase Deuel Dundy Fillmore Franklin Garden Garfield Greeley Hayes Hitchcock Holt Jefferson Johnson Logan Nance Nemaha Nuckolls Pawnee Perkins Red Willow Richardson Rock Sheridan Sherman Thayer Thomas Valley Webster and Wheeler. Nevada.The counties of Esmeralda Lander and Mineral. New Hampshire.Coos County. New Mexico.The counties of Harding and Quay. New York.The counties of Clinton and Montgomery. North Dakota.The counties of Adams Barnes Benson Billings Bottineau Burke Cavalier Dickey Divide Dunn Eddy Emmons Foster Golden Valley Grant Griggs Hettinger Kidder LaMoure Logan McHenry McIntosh McKenzie McLean Mercer Mountrail Nelson Oliver Pembina Pierce Ramsey Ransom Renville Sargent Sheridan Slope Stark Steele Stutsman Towner Traill Walsh Wells and Williams. Ohio.The counties of Crawford Monroe Paulding Seneca and Van Wert. Oklahoma.The counties of Alfalfa Beaver Cimarron Custer Dewey Ellis Grant Greer Harmon Harper Kiowa Major Roger Mills Seminole Tillman and Woodward. Pennsylvania.The counties of Venango and Warren. South Carolina.Marlboro County. South Dakota.The counties of Aurora Campbell Clark Day Deuel Douglas Faulk Grant Gregory Haakon Hand Harding Hutchinson Jones Kingsbury Marshall McPherson Miner Perkins Potter Sanborn Spink Tripp and Walworth. Texas.The counties of Andrews Bailey Baylor Borden Briscoe Brooks Castro Cochran Coleman Collingsworth Cottle Crane Culberson Deaf Smith Dimmit Eastland Fisher Floyd Foard Gray Hall Hardeman Haskell Hemphill Hockley Hutchinson Kenedy Kent Knox Lamb Martin McCulloch Morris Nolan Oldham Reagan Reeves Refugio Roberts Scurry Stonewall Terrell Terry Upton Ward Wheeler Wilbarger Winkler Yoakum and Zavala. Virginia.The counties of Buchanan Dickenson Highland and Lee and the independent cities of Clifton Forge Covington Norton and Staunton. West Virginia.The counties of Calhoun Gilmer Logan McDowell Mercer Mingo Summers Tucker Webster Wetzel and Wyoming. Wyoming.The counties of Carbon and Niobrara. -3-