This form, along with the 8850 form, should be forwarded to:
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WORK OPPORTUNITY TAX CREDIT SELF-ATTESTATION ELIGIBILITY QUESTIONNAIRE Our company is participating in a Federal jobs tax credit program. The information requested below is strictly confidential and will only be used for the purpose of securing WOTC tax credits. In compliance with company procedures, completed questionnaires, along with the IRS 8850 forms, should be forwarded to: Walton Management Services, Inc., 3321 Doris Ave., Ocean, NJ 07712. EMPLOYEE PLEASE COMPLETE BELOW AND SIGN BOTTOM: NAME ____________________________________________ ADDRESS_________________________________________________ CITY_______________________ STATE_________ZIP_____________ PHONE # __________________________________________________ SOCIAL SECURITY # _______________________________________ DATE OF BIRTH:_____________ Gender:____ AGE:___________ Please check only one answer for each of the following questions: 1. TO BE COMPLETED BY MANAGER: Avitus Group Company:________________________ Loc :_____________________________ Start Date:________________________ Job Title:_________________________ Hourly Rate: ______________________ If you are between the ages of 16 and 24, please respond to the following: a. Have you earned a high school diploma or a General Education Development (GED)? b. Have you attended high school, technical school, or community college more than approximately10 hours per week during the past 6 months? YES NO NOT SURE Date received: _____________ YES NO NOT SURE c. In the last six months, have you received a high diploma or GED certificate and have you been admitted or accepted to technical school or college? YES NO NOT SURE d. I have worked during the past 6 months, but I made less than $2800 for 3 months of work. YES NO NOT SURE 2. Have you or any member of your household received Aid to Families with Dependent Children (AFDC/TANF), Welfare payments, or General Assistance any time during in the last 2 years? Recipient’s Name __________________________________ Recipient’s SSN:________________________ Case #___________________ Relationship__________________ City & State Where Received_____________________ YES NO NOT SURE 3. Have you or any member of your household received Supplemental Nutrition Assistance Program (SNAP) benefits (Food Stamps) at any time during the last year? If yes, please provide: Recipient’s Name________________________________ Recipient’s SSN:________________ Relationship____________________________ Case #__________________________ City & State Where Received____________________ YES NO NOT SURE 4. Have you been convicted of a felony or released from prison in the last 12 months? Date of Conviction: ________________ Date of Release: ___________________ Parole Officer/Counselor Name: _______________________________________________ Parole Officer/Counselor Telephone Number:_____________________________________ YES NO NOT SURE 5. Are you currently participating in or have you recently completed a State or Veteran approved vocational rehabilitation agency or Ticket to Work program? Name of Agency ______________________________ Tel#: ( ) _______________________ Address of Agency __________________________________________________________ Counselor’s Name___________________________________________________________ YES NO NOT SURE 6. If you are a veteran, please respond to the following: 6a. A Veteran who is member of a family who has received food stamps (SNAP)? 7. (Discharge Date:______________) YES NO NOT SURE 6b. A Veteran certified as entitled to compensation for a service-connected disability YES NO NOT SURE 6c. A Veteran who has received unemployment in the last year? YES NO NOT SURE 6d. A Veteran unemployed for a combined period of six months during the past year? YES NO NOT SURE Have you received any SSDI or Supplemental Security Income (SSI) benefits within the last 60 days? YES NO NOT SURE I affirm that the above answers are accurate and correct. ___________________________________________ Employee Signature (Please sign here) ____________________ Date Copyright 2009, Walton Management Services, Inc. All rights reserved. For use only by client of Walton Management Services, Inc. 8850 Form (Rev. August 2009) Pre-Screening Notice and Certification Request for the Work Opportunity Credit Department of the Treasury Internal Revenue Service © OMB No. 1545-1500 See separate instructions. Job applicant: Fill in the lines below and check any boxes that apply. Complete only this side. Your name Social security number © Street address where you live City or town, state, and ZIP code Telephone number ( County If you are under age 40, enter your date of birth (month, day, year) / ) - / 1 Check here if you are completing this form before August 28, 2009, and you lived in the area impacted by Hurricane Katrina on August 28, 2005. If so, please enter the address, including county or parish and state where you lived at that time. 2 Check here if you received a conditional certification from the state workforce agency (SWA) or a participating local agency for the work opportunity credit. 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 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. 3 ● 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 discharged or released from active duty in the U.S. Armed Forces during the past 5 years and, for at least 4 weeks during the past year, I received unemployment compensation. ● I am at least age 16 but not age 25 or older, and: a During the past 6 months, I have not attended a secondary, technical, or post-secondary school for more than an average of 10 hours per week, not counting periods during which the school was closed for scheduled vacations, and 4 5 b During the past 6 months, if I was employed, during each consecutive 3-month period within the past 6 months, I earned less than I would have earned if I had worked for the applicable minimum wage 30 hours every week during the 3-month period, and c I do not have a certificate of graduation from a secondary school or a General Education Development (GED) certificate or I have a certificate that was awarded at least 6 months ago and I have not held a job (other than occasionally) or been admitted to a technical or post-secondary school since I received the certificate. Check here if you are a veteran entitled to compensation for a service-connected disability and, during the past year, you were: ● Discharged or released from active duty in the U.S. Armed Forces, or ● Unemployed for a period or periods totaling at least 6 months. 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. 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 © For Privacy Act and Paperwork Reduction Act Notice, see page 2. Date Cat. No. 22851L Form 8850 / / (Rev. 8-2009) CUESTIONARIO DE ELIGIBILIDAD PARA UN CREDITO FISCAL (WOTC QUESTIONNAIRE) Nuestra empresa está participando en un programa federal de crédito fiscal para empleados . La información solicitada en este formulario será utlizada solo para el propósito de obtener créditos fiscales de WOTC. De acuerdo con las pautas de la empresa, cuestionarios completados y los formulario IRS 8850 deben ser enviados a Walton Management Services, Inc., 3321 Doris Ave., Ocean, NJ 07712. EMPLEADO POR FAVOR COMPLETE Y FIRME ABAJO COMPLETADO POR GERENTE: Nombre ____________________________________________ Dirección _________________________________________________ Ciudad _____________________ Estado ___ Código Postal _____________ Número de Teléfono ____________________________________________ Número de Seguro Social ______________________________________ Fecha de Nacimiento:_____________ Género:____ Edad:___________ Por favor, marque sólo una respuesta por cada una de las siguientes preguntas: 1. Si usted tiene entre 16 y 24 años, por favor responda a las siguientes preguntas: Company:________________________ Avitus Group Loc :_____________________________ Start Date:________________________ Job Title:_________________________ Hourly Rate: ______________________ a. Recibí mi bachillerato (egresado de colegio secundario) o la Educación General Desarrollo (GED) hace más de seis meses O yo no lo recibí. SÍ NO NO SÉ Fecha de diploma: _________ b. Yo no he asistido colegio secundario (high school), un escuala técnica, ni el colegio de la comunidad (community college) por más de 10 horas por semana en los últimos 6 meses. SÍ NO NO SÉ c. En los últimos 6 meses, no he sido admitido ni he sido aceptado por una universidad o un instituto técnicos. SÍ NO NO SÉ d. Por 3 meses de los últimos 6 meses yo gané menos de $3100 o estuve desempleado. e. Será necesario para este empleador proporcioneme con las habilidades para realizar los deberes necesarios para este trabajo. SÍ NO NO SÉ SÍ NO NO SÉ 2.¿Ha Usted o alguna persona en su hogar recibido ayuda a familias con hijos dependientes (AFDC/TANF) o alguna ayuda pública en los últimos 2 años? Nombre de beneficiario ______________________ Relación a beneficiario ________________ Número de seguro social de beneficiario:______________________ Número de caso ________________ Ciudad y estado donde recibió ayuda _________________ SÍ NO NO SÉ 3.¿Ha Usted o alguna persona en su hogar recibido cupones de alimentación (Food Stamps) o ayuda del Programas “Supplemental Nutrition Assistance” en el último año? Si afirmativo, por favor responda: Nombre de beneficiario ______________________ Relación a beneficiario _____________Número de seguro social de beneficiario:____________ Número de caso ________________ Ciudad y estado donde recibió ayuda _________________ SÍ NO NO SÉ 4.¿ Ha sido condenado por un delito grave en los últimos 12 meses? Fecha de condena: ________________ Fecha de liberación: ___________________ Nombre de consejero u oficial de libertad condicional:__________________________________ Número telefónico de consejero u oficial de libertad condicional :_________________________ SÍ NO NO SÉ 5.¿Está usted participando o ha participado en un programa de rehabilitación vocacional o programa “Ticket to Work” aprobado por el estado o agencia de veteranos? Nombre de Agencia _____________________________ Tel#: ( ) _____________________ Dirección de Agencia _____________________Nombre de consejero____________________ SÍ NO NO SÉ 6.Si Usted es un veterano, por favor responda a las siguientes preguntas: Fecha de baja de servicio militar: ______________ 6a. ¿Ha recibido Usted o su familia cupones de alimentación (SNAP)? 6b. ¿Es Usted certificado como elegible para compensación por discapacidad relacionado a su servicio militar? SÍ NO NO SÉ SÍ NO NO SÉ 6c. ¿Ha recibido un subsidio de desempleo en el último año? SÍ NO NO SÉ 6d. ¿Ha estado sin empleo por un total de 6 meses durante el último año? SÍ NO NO SÉ 7.¿Ha recibido Usted ayuda pública de SSDI o Supplementary Security Income (SSI) durante los últimos 60 dias? SÍ NO Yo afirmo que las respuestas anteriores son exactas y correctas. ___________________________________________________ Firma del empleado (por favor firme aquí) ___________________ La Fecha Copyright 2009, Walton Management Services, Inc. All rights reserved. For use only by client of Walton Management Services, Inc. NO SÉ AVISO: USTED DEBE LLENAR EL FORMULARIO EN INGLES ESTA TRADUCION ES SOLO UNA AYUDA PARA LLENAR DICHO FORMULARIO Form 8850 (Rev. August 2009) Pre-Screening Notice and Certification Request for the Work Opportunity and Welfare-to-Work Credits Department of the Treasury Internal Revenue Service OMB No. 1545-1500 ►See separate instructions. Solicitante de Trabajo: Llena los siguientes blancos y marca con una (X) los encasillados que apliquen. Llena sólo este lado. Su Nombre ________________________________________Número de Seguro Social ►_____________________ Dirección de la Calle Donde Usted Vive ___________________________________________________ Pueblo o Ciudad y Código Postal________________________________________________________ Condado________________________________ Número de Teléfono ( )__________________________ Si Usted Tiene Menos de 40 Años Escriba Su Fecha de Nacimiento Aquí (mes, día, año) / / . 1 Marque aquí si Usted esta llenando este formulario antes del 28 de agosto del 2009 y si vivió en el área afectada por el Huracán Katrina durante el 28 de agosto del 2005. Si su contestación es afirmativa (Si), escriba su dirección incluyendo el condado o parroquia y el estado donde vivió durante esa época. _________________________________________________________ 2 Marque aquí si Usted recibió Certificación Condicional de la agencia de empleo estatal (SWA) o de una agencia local para participar en el Programa de crédito fiscal (work opportunity tax credit, WOTC). 3 Marque aquí si una de las siguientes situaciones aplican a Usted. • Soy miembro de una familia que ha recibido “Ayuda Provisional a Familias Necesitadas” (TANF) o beneficio durante cualquier periodo de 9 meses en los últimos 18 meses. •Soy veterano y miembro de una familia que recibió Cupones de Alimentos (SNAP) durante un periodo de por lo menos 3-meses dentro de los últimos 15 meses. •Fui referido aquí por una Agencia de Rehabilitación Vocacional, una oficina en la red de empleo del programa “Ticket to Work” o la Administración de Asuntos de Veteranos. •Tengo por lo menos 18 años y no más de 40 años y soy miembro de una familia que: a. recibió Cupones de Alimentos (SNAP) durante los últimos 6 meses, o b. recibió Cupones de Alimentos (SNAP) por lo menos durante 3 de los últimos 5 meses, PERO ya NO está elegible. •Durante el año pasado, fui convicto por una felonía/delito o salí libre de la cárcel. •Recibí beneficios de “Ingreso por Seguro Suplemental” (SSI) durante cualquier mes en los últimos 60 días. •Soy veterano y recibí la baja de servicio militar (discharge) durante los últimos 5 años, y recibí por 4 semanas o más durante el año pasado subsidio de desempleo. •Tengo no menos de 16 ni más de 24años, y: a. Durante los últimos 6 meses, no he asistido a un colegio secundario, técnico, o escuela post-secundaria por más de un por medio de 10 horas por semana, no incluyendo los periodos cuando la escuela estuvo cerrada por vacaciones programadas, y b. Durante los últimos 6 meses, si estuviera empleado, durante cada periodo de 3 meses consecutivos, gane menos de lo que hubiera ganado por un salario mínimo trabajando por 30 horas cada semana por 3 meses, y c. No tengo un diploma o certificado de graduación de una escuela secundaria o un diploma de equivalencia (GED); o recibí un diploma o certificado en los últimos 6 meses y no he tenido empleo o sido admitido a una escuela post-secundaria o técnica. 4 Marque aquí si Usted es un veterano elegible para compensación por discapacidad relacionado a su servicio militar y si durante el último año Usted: •Salió del servicio activo militar o •Estuvo sin empleo por un total de 6 meses o más. 5. Marque aquí si Usted es un miembro de una familia que: •recibió beneficios de “Ayuda Provisional a Familias Necesitadas” (TANF) por los menos durante los últimos 18 meses consecutivos, •recibió beneficios de “Ayuda Provisional a Familias Necesitadas” (TANF) durante cualquier periodo de 18 meses comenzando después del 5 de agosto de 1997, y el periodo mas reciente de 18 meses de beneficios recibidos después del 5 de agosto 1997 terminó en los últimos dos años, o •Dejó de ser elegible para recibir beneficios de “Ayuda Provisional a Familias Necesitadas” (TANF) en los últimos 2 años porque una ley Federal o estatal limitó el periodo máximo para Ud. recibir dichos beneficios. Todos los Solicitantes Tienen Que Firmar Bajo penalidad de perjurio, declaro que ofrecí esta información al patrono en o antes del día en que se me ofreció empleo, y es verdadera, correcta y completa. Firma del Solicitante ► __________________________________________Fecha: ____/_______ ____/ For Privacy Act and Paperwork Reduction Act Notice, see page 2 Cat. No. 22851L Forma 8850 (Rev. 8- 2009) OMB Control No. 1205-0371 Expiration Date: November 30, 2011 YOUTH SELF-ATTESTATION FORM Work Opportunity Tax Credit Program Instructions: This Self-Attestation Form (SAF) is to be completed, signed and dated by the new hire on or before the day the job offer is made. The employer or consultant is to submit the SAF to the state workforce agency together with IRS Form 8850 within 28 calendar days from the employment start date of the new hire. New Hire Name: ___________________________________________________________ Social Security Number: _________________ Date of Birth:_______________________ Employer Name: ___________________________________________________________ Employer Federal ID (EIN) Number: ___________________________________________ Please check all the statements that apply to you. Sign and date this form where indicated below. In the past 6 months, I have not attended a secondary, technical or postsecondary school for more than an average of 10 hours per week, not counting periods during which the school is closed for scheduled vacations. I do not have a High School Diploma or GED certificate. I have a High-School diploma or GED certificate awarded more than 6 months ago and I have not attended or been admitted to a technical or post-secondary school. I also have not held a job (other than occasionally) since receiving my High-School diploma or GED certificate. Under penalties of perjury, I declare that this information is true and correct to the best of my knowledge. New Hire’s Signature: _______________________________________________Date_________ Public Burden Statement: Persons are not required to respond to this collection of information unless it displays a currently valid OM B control number. Respondents' obligation to complete this form is required to obtain or retain benefits (P.L. 111-5). Public reporting burden is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of Information. Send comments regarding this burden estimate to the U.S. Department of Labor, Division of Adult Services, Room S-4209, Washington, D.C. 20210 (Paperwork Reduction Project 1205-0371). ETA Form 9154 (February 2010)
