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Form 8850 (Rev. March 2016) | Department of the Treasury - Internal Revenue Service

Pre-Screening Notice and Certification Request

for the Work Opportunity Credit

INSTRUCTIONS FOR JOB APPLICANT:

Complete this form and give it to your prospective employer. This form helps determine if the employer may be eligible for a tax credit for hiring you. Your answers will not affect your eligibility for employment.

Note: This form must be completed on or before the day a job offer is made.

JOB APPLICANT INFORMATION
TARGET GROUP ELIGIBILITY - Check all boxes that apply

Check all that apply. If you check a box, you may be asked to provide documentation.

APPLICANT CERTIFICATION

Under penalties of perjury, I declare that the information I have provided on this form is, to the best of my knowledge, true, correct, and complete. I understand this information may be verified by the employer and/or the state workforce agency.

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FOR EMPLOYER USE ONLY

Employment Information

Important Deadlines:

  • • Form 8850 must be completed on or before the day a job offer is made
  • • Employer must submit to the State Workforce Agency within 28 days of the employee's start date
  • • Pennsylvania WOTC submissions: PA UC WOTC Portal

Form 8850 (Rev. 3-2016) | Cat. No. 22851L

PA WOTC Portal