Tax Opportunities of America

First Name*

Middle Name

Last Name*

Date of birth*

Social Security* #

Street Address*

Apt # (optional)

City*

State*

ZIP*

Country

Phone*

Email*

Position*

Hourly Wage*

Date Applied for Job

Date Offered Job

Date Hired*

Date Started Job

Have you worked for this employer (at this entity) in the past?*

Yes No

Most recent date of work

Are you a Veteran of the U.S. Armed Forces?*

Yes No

Are you a member of a family that received SNAP benefits (Food Stamps) - Supplemental Nutrition Assistance Program for the 6 months before you were hired?*

Yes No Not Sure

Are you a member of a family that received SNAP benefits (Food Stamps) - Supplemental Nutrition Assistance Program for at least a 3-month period within the last 5 months but you are no longer receiving them?*

Yes No Not Sure

Family Member (SNAP Recipient) Name*

Family Member (SNAP Recipient) City*

Family Member (SNAP Recipient) State*

Were you referred to an employer by a Vocational Rehabilitation Agency approved by a State?

Yes No Not Sure

Were you referred to an employer by a Vocational Rehabilitation Agency approved by an Employment Network under the Ticket to Work Program?

Yes No Not Sure

Were you referred to an employer by a Vocational Rehabilitation Agency approved by the Department of Veterans Affairs?

Yes No Not Sure

Are you or your spouse a member of a Native American Tribe?*

Yes No Not Sure

What is the name of your tribe?

Certificate of Degree of Indian Blood #

Are you a member of a family that received Temporary Assistance for Needy Families (TANF) or Welfare Assistance benefits for at least 18 months before you were hired?*

Yes No Not Sure

Are you a member of a family that received Temporary Assistance for Needy Families (TANF) or Welfare Assistance benefits for any 18 months beginning after August 5, 1997, AND the earliest 18-month period beginning after August 5, 1997, ended within 2 years before you were hired?*

Yes No Not Sure

Did your family stop being eligible for Temporary Assistance for Needy Families (TANF) or Welfare Assistance benefits within 2 years before you were hired because a Federal or state law limited the maximum time those payments could be made?*

Yes No Not Sure

Are you a member of a family that received Temporary Assistance for Needy Families (TANF) or Welfare Assistance benefits for any 9 months during the 18-month period before you were hired?*

Yes No Not Sure

Family Member (TANF Recipient) Name*

Family Member (TANF Recipient) City*

Family Member (TANF Recipient) State*

Were you convicted of a felony or released from prison after a felony conviction during the year before you were hired?

Yes No

Date of conviction

Date of release

Federal or State conviction?

Federal State

Did you receive SSI (Supplemental Security Income) benefits for any month ending within 60 days before you were hired?*

Yes No

Did you receive a conditional certification from the SWA (State Workforce Agency) or a participating local agency for the work opportunity credit?

Yes No

Were you unemployed for at least 27 weeks?*

Yes No

Unemployment Start Date

Unemployment End Date

I declare I have received unemployment compensation/benefits under State or Federal law during a period of unemployment.

Yes No

Agreement:

I affirm that I meet one of the categories listed above
I understand that I must provide private, personal information on this application to qualify for the program.
I understand that I do not need to explain why I qualify to anyone I ask for a job, or who gives me a job, or anyone who I work with.
I agree to allow the New York State Department of Taxation and Finance to share my wage record with the New York State Department of Labor.
I believe the information submitted in this application is true, correct and complete.
I understand that the New York State Department of Labor will make sure the information submitted in this application is true and may ask me for more information or details.
I am aware that there are consequences for filing false documents or other information with the government.
I also allow Tax Opportunities of America to submit this application on my behalf.

If you believe that you do not meet one of the categories (risk factors) listed above, please email info@taxoa.com or call 718-705-9003

This company participates in federal and state tax credit programs, including the Work Opportunity Tax Credit (WOTC). Participation is voluntary and not a condition of employment, and my responses will not affect any hiring, retention, or other employment decision. Under penalty of perjury, I certify that the answers I provided are true, correct, and complete to the best of my knowledge and belief and that, based on my responses and to the best of my knowledge, I meet or may meet the criteria for one or more applicable targeted groups as of the date I was offered employment. I authorize my employer and its designated agents to use this information to complete and submit IRS Form 8850 and any required documentation to the appropriate state workforce agency and to federal, state, or local government agencies for tax credit eligibility purposes. I understand that my Social Security number may be required for tax credit eligibility determination and that the information provided may be subject to verification, and I acknowledge that by submitting this form, I am electronically signing this certification. Information will be used in a manner consistent with applicable disability-related laws.

Signature

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Confirm Signature - I certify that I have read the above.

For any questions, email info@taxoa.com, or call (718) 705-9003

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Care Stat Staffing LLC

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