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8850
Form
(Rev
...
1545-1500
Information about Form 8850 and its separate instructions is at www
...
gov/form8850
...
Complete only this side
...
2
Check here if any of the following statements apply to you
...
• 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 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 at least 3 of the past 5 months, but is no longer eligible to receive them
...
• I received supplemental security income (SSI) benefits for any month ending during the past 60 days
...
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
...
S
...
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
...
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
...
Date
Job applicant’s signature
For Privacy Act and Paperwork Reduction Act Notice, see page 2
...
No
...
3-2016)
Page 2
Form 8850 (Rev
...
EIN
Street address
City or town, state, and ZIP code
Person to contact, if different from above
Telephone no
...
Date applicant:
Gave
information
Was
offered job
Was
hired
Started
job
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
...
I hereby request a certification that the individual is a member of a targeted group
...
Section 51(d)(13) permits a prospective
employer to request the applicant to
complete this form and give it to the
prospective employer
...
Completion of this form is
voluntary and may assist members of
targeted groups in securing employment
...
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
Title
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
...
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
...
Generally, tax returns and return
information are confidential, as required
by section 6103
...
The estimated
average time is:
Recordkeeping
...
6 hr
...
Learning about the law
or the form
...
...
Preparing and sending this form
to the SWA
...
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
...
irs
...
Click on “More
Information” and then on “Give us
feedback
...
NW, IR-6526
Washington, DC 20224
Do not send this form to this address
...
Form
8850
(Rev