Form 8850 (Rev. 3-2016)
Page 2
For Employer’s Use Only
Employer’s name Telephone no. EIN
▶
Street address
City or town, state, and ZIP code
Person to contact, if different from above Telephone 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 member of group 4 or 6 (as described under Members of
Targeted Groups in the separate instructions), enter that group number (4 or 6) . . . . . . . . . . . . . .
▶
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. 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
▶
Title Date
Privacy Act and
Paperwork Reduction
Act Notice
Section references are to the Internal
Revenue Code.
Section 51(d)(13) permits a prospective
employer to request the applicant to
complete this form and give it to the
prospective employer. The information
will be used by the employer to
complete the employer’s federal tax
return. Completion of this form is
voluntary and may assist members of
targeted groups in securing employment.
Routine uses of this form include giving
it to the state workforce agency (SWA),
which will contact appropriate sources
to confirm that the applicant is a
member of a targeted group. 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
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. We
may also disclose this information to
other countries under a tax treaty, to
federal and state agencies to enforce
federal nontax criminal laws, or to
federal law enforcement and intelligence
agencies to combat terrorism.
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. Books or records
relating to a form or its instructions must
be retained as long as their contents
may become material in the
administration of any Internal Revenue
law. Generally, tax returns and return
information are confidential, as required
by section 6103.
The time needed to complete and file
this form will vary depending on
individual circumstances. The estimated
average time is:
Recordkeeping . . 6 hr., 27 min.
Learning about the law
or the form . . . . . . . 24 min.
Preparing and sending this form
to the SWA . . . . . . . 31 min.
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. You can send us comments from
www.irs.gov/formspubs. Click on “More
Information” and then on “Give us
feedback.” Or you can send your
comments to:
Internal Revenue Service
Tax Forms and Publications
1111 Constitution Ave. NW, IR-6526
Washington, DC 20224
Do not send this form to this address.
Instead, see When and Where To File in
the separate instructions.
Form 8850 (Rev. 3-2016)
click to sign
signature
click to edit
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