WOTC Form
Step
1
of
6
16%
Company Name
*
Company EIN Number
Have you ever worked for this Employer before? Are you a Re-Hire?
*
YES
NO
Are you under 40?
*
YES
NO
Have you been unemployed for at least 27 weeks, and collected Unemployment Insurance?
*
YES
NO
Are you a Veteran of the US Armed Forces?
*
YES
NO
If Yes,
Are you a member of a family that received SNAP (Food Stamps Benefits)?
*
YES
NO
N/A
Are you entitled to compensation for a service-connected disability?
*
YES
NO
N/A
Were you discharged from active duty within the last year?
*
YES
NO
N/A
Were you unemployed for a combined total of 6 months before you were hired?
*
YES
NO
N/A
Have you, or your family, received SNAP benefits (Food Stamps) in the 6 months before you were hired?
*
YES
NO
Or received SNAP Benefits for at least a 3-month period, but you are no longer receiving it?
*
YES
NO
If yes to either question, enter Name of Primary Recipient:
And City, State where benefits were received:
Are you a member of a family that received TANF assistance for at least 18 months before you were hired?
*
YES
NO
Or, did your family stop being eligible for TANF assistance within 2 years before being hired, because you reached the maximum time those benefits can be received?
*
YES
NO
If yes to either question, enter Name of Primary Recipient:
And City, State where benefits were received:
Did you receive Supplemental Security Income (SSI Benefits) for any month, ending within the 60 days, before you were hired?
*
YES
NO
Were you convicted of a Felony during the year before you were hired?
*
YES
NO
Were you referred to an employer by:
A Vocational Rehab Agency approved by the state?
*
YES
NO
An Employment Network under the Ticket to Work Program?
*
YES
NO
The Dept. of Veteran Affairs?
*
YES
NO
Name
*
First
Last
Social Security Number
*
Date of Birth
*
Email
*
By signing this form, I hereby authorize any agency, organization, Social Security Administration, Department of Veterans Affairs, or individuals, to supply verification of information as may be needed to determine tax credit eligibility to my employer, employer representative (TC Services USA, Inc. dba WOTC.com), or the Department of Labor. I also understand that my responses are used, in part or in full, to complete the IRS Form 8850 and any other documents pertaining to the WOTC Program, and that modifications can be made by my employer, or employer representative, in order to enable the verification screening process as required by some states. This information will not in any way affect my employment.
Employment Start Date
*
Starting Wage
*
Position
*
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X
