Irs Form 8850 – Fill Out and Use This PDF

Your name

Social security number ▶

County

Telephone number

Job applicant’s signature ▶

Date

For Privacy Act and Paperwork Reduction Act Notice, see page 2.

Cat. No. 22851L

Form 8850 (Rev. 3-2016)

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

Targeted Groups in the separate instructions), enter that group number (4 or 6) . . .

. . . . . . . . . . . ▶

Date applicant:

Gave

Was

Was

Started

information

offered job

hired

job

Employer’s signature ▶

Title

Date

Privacy Act and

criminal litigation, to the Department of

The time needed to complete and file

Paperwork Reduction

Labor for oversight of the certifications

this form will vary depending on

performed by the SWA, and to cities,

individual circumstances. The estimated

Act Notice

states, and the District of Columbia for

average time is:

use in administering their tax laws. We

Recordkeeping

. .

6 hr., 27 min.

Section references are to the Internal

may also disclose this information to

Learning about the law

Revenue Code.

other countries under a tax treaty, to

Section 51(d)(13) permits a prospective

federal and state agencies to enforce

or the form

.

. 24 min.

federal nontax criminal laws, or to

Preparing and sending this form

employer to request the applicant to

federal law enforcement and intelligence

complete this form and give it to the

to the SWA

.

. 31 min.

agencies to combat terrorism.

prospective employer. The information

If you have comments concerning the

You are not required to provide the

will be used by the employer to

accuracy of these time estimates or

complete the employer’s federal tax

information requested on a form that is

suggestions for making this form

return. Completion of this form is

subject to the Paperwork Reduction Act

simpler, we would be happy to hear from

voluntary and may assist members of

unless the form displays a valid OMB

you. You can send us comments from

targeted groups in securing employment.

control number. Books or records

www.irs.gov/formspubs. Click on “More

Routine uses of this form include giving

relating to a form or its instructions must

Information” and then on “Give us

it to the state workforce agency (SWA),

be retained as long as their contents

feedback.” Or you can send your

which will contact appropriate sources

may become material in the

comments to:

to confirm that the applicant is a

administration of any Internal Revenue

member of a targeted group. This form

law. Generally, tax returns and return

Internal Revenue Service

may also be given to the Internal

information are confidential, as required

Tax Forms and Publications

Revenue Service for administration of

by section 6103.

1111 Constitution Ave. NW, IR-6526

the Internal Revenue laws, to the

Washington, DC 20224

Department of Justice for civil and

Do not send this form to this address.

Instead, see When and Where To File in

the separate instructions.