Introduction

Introducción

Welcome

This company participates in the federal government's Work Opportunity Tax Credit program, other federal and state tax credit programs, and/or government health insurance programs. The information you supply will be used by or on behalf of this company to complete it's Federal and State tax returns and/or determine health insurance eligibility and may assist members of targeted groups in securing employment. Your responses to the questions will be confidential to this company's management and third party service providers, Federal, State, and Local agencies, and other third parties as necessary to determine eligibility. Please answer all of the questions truthfully and honestly. This interview process takes about 3 - 4 minutes to complete. Thank You!

Work Location Information

*What state is your workplace located?

*What location will you be working at?

*Have you worked at this location previously? Yes No



Personal Information

*Last Name

Social Security #

*Date of Birth

Phone Number

E-mail Address

Employee Address:

*Street

Apt/Unit #

*City

*State/Region

*Postal Code





Work Information

Hire Date

Pay Rate /hr

Job Title

Questionnaire

Cuestionario

Veteran Status

Are you a veteran of the U.S. Armed Forces? Yes No



Long-Term Unemployment

Did you receive unemployment benefits at any time during the last 6 months? Yes No



SNAP Benefits/Food Stamps

Have you or any member of your household received SNAP benefits over the past 18 months? Yes No



Temporary Assistance to Needy Families (TANF)/Welfare

Have you or any member of your household received cash assistance from the government, such as TANF or Welfare over the past 18 months? Yes No



SSI/SSDI

Have you recieved any SSI or Disability benefits within the last 60 days prior to being hired? Yes No



Ex-Felon Status

Were you convicted of a felony or released from prison in the last year? Yes No





Outside Agency

Have you applied to any organization or agency for help finding your job, such as the Veterans Affairs, Vocational Rehabilitation Agency, or the Ticket to Work Program?
Yes No




E-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.

Please, provide today's date and check the checkbox to acknowledge and accept the above statement and e-sign form 8850.

I agree to the above statement.

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