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WOTC Form
RS Consulting
2023-03-10T01:22:36-05:00
CCS Online Application WOTC 2022
Work Opportunity Tax Credit Program (WOTC)
Our company participates in the Work Opportunity Tax Credit Program. Your responses to the following questions will be confidential and used only to assist us in complying with the requirements of this program. Your answers will not affect your employment or any benefits you may be receiving. Thank you for your cooperation!
Name
Address
*
Street Address
City
State
Zip Code
Phone
*
Social Security #
*
Date of Birth
*
MM slash DD slash YYYY
Position
Wage
Hire Date
MM slash DD slash YYYY
Have you worked for this employer before?
*
Yes
No
Have you, or any immediate member of your family, EVER received Temporary Assistance to Needy Families (TANF, Welfare)?
*
Yes
No
Have you, or a member of your family, received Supplemental Nutrition Assistance Program (SNAP) benefits (FOOD STAMPS) ANYTIME over the last 6 months?
*
Yes
No
Have you been unemployed for the last 6 months AND received unemployment compensation at ANY TIME?
*
Yes
No
Have you personally received Supplemental Security Income (SSI) or (SSDI) Supplemental Security Disability Income anytime during the last 2 months?
*
Yes
No
Have you participated in a rehab program approved by the state, the Ticket to Work program, or the Department of Veterans Affairs.
*
Yes
No
Are you a Veteran of the United States Armed Forces
*
Yes
No
Are you a Veteran who received Supplemental Nutrition Assistance Program (SNAP) benefits (FOOD STAMPS) ANYTIME over the last 6 months.
*
Yes
No
Are you a Veteran who was unemployed for more than 4 weeks, but less than 6 months, during the past year
*
Yes
No
Are you a Veteran who was unemployed for more than 6 months during the past year.
*
Yes
No
Are you a Veteran discharged from active duty within the last 12 months and entitled to compensation for a service connected disability.
*
Yes
No
Are you a Veteran receiving compensation for a service connected disability who was unemployed for at least 6 months during the last 12 months.
*
Yes
No
During the last 12 months, were you convicted of a felony or released from prison for a felony.
*
Yes
No
Hidden
Have you worked for this employer before? - Depreciated
Yes
No
Hidden
Have you, or a member of your family, received Supplemental Nutrition Assistance Program (SNAP) benefits (FOOD STAMPS) ANYTIME over the last 6 months? - Depreciated
Yes
No
Hidden
Have you been unemployed for the last 6 months AND received unemployment compensation at ANY TIME? - Depreciated
Yes
No
Hidden
Have you personally received Supplemental Security Income (SSI) or (SSDI) Supplemental Security Disability Income anytime during the last 2 months. - Depreciated
Yes
No
Hidden
Have you participated in a rehab program approved by the state, the Ticket to Work program, or the Department of Veterans Affairs. - Depreciated
Yes
No
Hidden
Are you a Veteran of the United States Armed Forces - Depreciated
Yes
No
Hidden
Are you a Veteran who received Supplemental Nutrition Assistance Program (SNAP) benefits (FOOD STAMPS) ANYTIME over the last 6 months. - Depreciated
Yes
No
Hidden
Are you a Veteran who was unemployed for more than 4 weeks, but less than 6 months, during the past year - Depreciated
Yes
No
Hidden
Are you a Veteran who was unemployed for more than 6 months during the past year. - Depreciated
Yes
No
Hidden
Are you a Veteran discharged from active duty within the last 12 months and entitled to compensation for a service connected disability. - Depreciated
Yes
No
Hidden
Are you a Veteran receiving compensation for a service connected disability who was unemployed for at least 6 months during the last 12 months. - Depreciated
Yes
No
Hidden
During the last 12 months, were you convicted of a felony or released from prison for a felony. - Depreciated
Yes
No
I agree that I am voluntarily providing the information on this form and it is not a condition of employment. My signature authorizes the release of information to the Department of Veterans Affairs, Department of Health and Human Services, Social Security Administration, and other Federal State, and local governments agencies to release information to the client., to verify my eligibility for WOTC. I authorize this form to assist in the completion of IRS Form 8850 and ETA Form 9061. Under penalties of perjury, I declare I provided the information on this form on or before the day a job was offered and that the information I have furnished is, to the best of my knowledge, true, correct, and complete.
Signature
Date
MM slash DD slash YYYY
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