WOTC.com

Personal Information Last Name Other Last Names Used (if any) Date of Birth Social Security # Street Address Apt, Suite, PO Box # (Optional) City State County Zip Code Email Address Employment Info Did you ever work for this employer before?Date you applied for job Date you started job. Starting Wage (per hour) Government Assistance (Check all that apply) Are you a member of a family that received SNAP Benefits (Supplemental Nutrition Assistance Program), or Food Stamps: City / State where benefits received: Enter start date of unemployment benefits: State where benefits received: Date of conviction Date of release Federal Conviction Employee Signature By signing this form I agree that this information is true and correct Submit For the 6 months before you were hired? Or, for at least 3 of the past 5 months, but you are no longer receiving them? Are you a member of a family that received TANF (Temporary Assistance for Needy Families), or Cash Benefits? For any 9 months during the past 18 months before you were hired? Or, for any 18 Months beginning after August 5, 1997 and ending within the past 2 years? Or, did your family stop being eligible within the last 2 years because the law limited the maximum time those payments can be made? Did you receive SSI Benefit (Supplemental Security Income) for any month ending within 60 Days before you were hired? Have you received a conditional certification from a State Workforce Agency (SWA), or a participating local agency for the Work Opportunity Credit? Have you been unemployed for at least 27 consecutive weeks, and collected any Unemployment Compensation during that time? Employee Status & Referrals Are you a Veteran of the US Armed Forces? Are you a veteran entitled to compensation for a service-connected disability? Do you live in a Rural Renewal Community or an Empowerment Zone? Were you referred to an employer by a Vocational Rehab Agency approved by the State? Were you referred by an Employment Network, under the Ticket to Work Program? Were you referred by the Dept. of Veteran Affairs? Applicant Signature & Date Are you a member of a family that received Supplemental Nutrtion Assistance Program (SNAP) benefits (Food Stamps) for at least 3 months during the 15 months before you were hired? Were you unemployed for at least 6 months before you were hired? Were you unemployed for less than 6 months before you were hired? Primary Recipient Name: State conviction City and State where benefits were received Processing... You are seeing this message because this page has expired please reload. Reload Form Error Close Were you discharged or released from active duty within a year before you were hired? Where you unemployed for a combined period of at least 6 months (whether or not consecutive) during the year before you were hired? Were you Convicted of a Felony, or released from prison during the year before you were hired? Today's Date New Hire Tax Credit Survey Select State First Name, Middle Name Contact Number Do you have a work start date? Work Start Date Position Applied Have you received any type of Vocational Rehabilitation services within the past two years? Received vocational rehabilitation services from a Vocational Rehabilitation Agency? Received vocational rehabilitation services from Dept. of Veteran Affairs? Received vocational rehabiliation services from an Employment Network, under the Ticket to Work Program? 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. Sign with your Computer Mouse or your finger within this box. Previous Next Applicant Info WOTC Questionnaire Sign and Submit Applicant Information Clear Gender Male Female State where benefits received Are you a member of a family that received TANF (Temporary Assistance for Needy Families), or Cash Benefits: First Name, Middle Name Last Name Full Name Gender Male Female Apt. Number Street Address eg:- Fifth Avenue Address City State Zip Code Apt, Suite, PO Box # Date of Birth Social Security # Contact Number Email Address [email protected] Have you worked for this employer before? Enter your last day of employment with this employer Last day of employment Have you started working yet? Employment Start Date Date you applied for job Job Position Eg:- Sales Manager Starting Wage Hourly basis Name of the Recipient City/State I am a member of a family that received SNAP Benefits (food stamps) for the past 6 months: For the 6 months before you were hired? Or, for at least 3 of the past 5 months, but you are no longer receiving them? Primary Recipient Name: City / State where benefits received: I am a member of a family that received assistance from Temporary Assistance (TANF): For any 9 months during the past 18 months before you were hired? Or, for any 18 Months beginning after August 5, 1997 and ending within the past 2 years? Or, did your family stop being eligible within the last 2 years because the law limited the maximum time those payments can be made? I received SSI Benefit (Supplemental Security Income) for any month ending within 60 Days before being hired: I have received a conditional certification from a State Workforce Agency (SWA), or a participating local agency for the Work Opportunity Credit: I have been unemployed for at least 27 consecutive weeks and collected Unemployment Compensation during that time: Enter start date of unemployment benefits: State where benefits received I am a Veteran of the US Armed Forces: Are you a veteran entitled to compensation for a service-connected disability? Were you discharged or released from active duty within a year before you were hired? Where you unemployed for a combined period of at least 6 months (whether or not consecutive) during the year before you were hired? Are you a member of a family that received Supplemental Nutrtion Assistance Program (SNAP) benefits (Food Stamps) for at least 3 months during the 15 months before you were hired? Were you unemployed for at least 6 months before you were hired? Were you unemployed for less than 6 months before you were hired? I was Convicted of a Felony or released from prison during the year before I was hired Date of conviction Date of release Federal Conviction State conviction I live in a Rural Renewal Community or an Empowerment Zone: I have received Vocational Rehabilitation services within the past two years: Received vocational rehabilitation services from a Vocational Rehabilitation Agency? Received vocational rehabilitation services from Dept. of Veteran Affairs? Received vocational rehabiliation services from an Employment Network, under the Ticket to Work Program? Employee Signature The information contained in this application is correct and to the best of my knowledge. 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. Sign with your Computer Mouse or your finger within this box. Today’s Date Clear Submit I attest, under penalty of perjury, that I am (check one of the following boxes): I attest, under penalty of perjury, that I am: 1. A citizen of the United States 2. A noncitizen national of the United States (See instructions) 3. A lawful permanent resident (Alien Registration Number/USCIS Number) No Expiration Date 4. An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy): Some aliens may write "N/A" in the expiration date field. An alien authorized to work until Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number. Alien Registration Number/USCIS Number Alien Registration/USCIS Form I-94 Admission Number I-94 Number Foreign Passport Number Country of Issuance Add Preparer, Translator or Notary Public Remove Preparer, Translator or Notary Public Enter Authority Employee Info Citizenship/Immigration Status (List-A) Identity & Employement Authorization (List-B & List-C) Identity & Employement Authorization List A List B List C Select Document Type Identity Documents Document Title Issuing Authority Document Number Expiration Date if any Additional Information I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States. Enter Document Number Enter Additional Information Sign with your Computer Mouse or your finger within this box. I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct. Notary Public Number (Optional) Address Signature of Preparer or Translator Preparer/Translator Notary Public Number Please drop files into the box below. You can also click on the file icon or 'browse' text to browse your files from system. Drop your file here, or Browse Supports: .pdf, .jpg, .jpeg, .bmp, .png Max 6 files are allowed with each one of max 2 MB Upload Document Uploading... Ready to Upload Already Uploaded Enter Full Name Enter Relationship Food, Medication, Insects, Etc Medical alerts if any Primary Emergency Contact Contact Name Relationship to Contact Cellular Telephone Home Telephone Email Secondary Emergency Contact Add Secondary Emergency Contact Remove Secondary Emergency Contact Additional Information (Optional) Allergies Medical Alerts Additional Information Are you 16 or 17 years old and have the permission of your parent of guardian to submit this application? Parent or Guardian Name Are you 18 – 24 years old? Do you have a high school diploma, a GED or HSE diploma, satisfactorily completed a TASC exam, or are you enrolled in a TASC program? Were you unemployed prior to being hired or did you not have enough paid work? Confirm that you currently meet one or more of the youth categories listed below I am over 18 and do not have a high school diploma of GED/HSE diploma. I am a member of a family that is receiving assistance from TANF. I am a member of a family that is receiving SNAP benefits (food stamps). I am a member of a family that is receiving SSI benefits. I am receiving a free of reduced-cost school lunch. I have served in jail or prison, or am on probation or parole. I am pregnant or a parent. I am currently or was in foster care of the custody of the Office of Children and Family Services. I am a veteran. I am the daughter or son of a parent who is currently in jail or prison, or has been within in the past two years. I am the daughter or son of a parent who is collecting unemployment insurance. I live in public housing or receive housing assistance such as a Section 8 voucher, or is homeless. Another risk factor not identified above I confirm that I currently meet one or more of the youth categories listed above Agreement I have provided my private information on this application. While I need to disclose this information to qualify for the program, I understand that I do not need to explain the reasons I choose to anyone I ask for a job, who gives me a job, or who I work with. I agree to allow the New York State Department of Taxation and Finance to share my wage records with the New York State Department of Labor. 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 details. I believe this information is correct and complete. I am aware that there are consequences for filing false documents or other information with the government. I agree to the statement above and I allow my employer or employer representative, to submit this application on my behalf Enter Amount Here Enter bank name Enter Account Number Enter Percentage Here Wage Details Hourly Amount Salary Amount Salary Amount Period Amount Type Amount Bank Name City & State Routing & Transit Number Routing & Transit #(9 digit number between these two symbols) Account Number Checking Account # (Usually Follows The Routing & Transit Account Type Checking Savings None Paycard Deposit Amount Specific Amount Percentage of Net Pay Entire Net Pay / Remaining Net Pay Upload Voided Check Note* - Please upload the void check in Upload Documents Section Add Bank Account Remove Bank Account Federal / State filing status Number of allowances / dependants Have you used another name in the past? Have you used another name in the past? What is your former or previous address? Enter First Name, Middle Name Enter Last Name Driver’s License Number Driver's License Issued By State I hereby authorize and its designated agents and representatives to conduct a comprehensive review of my background causing a consumer report and/ or an investigative consumer report to be generated for employment and/or volunteer purposes. I understand that the scope of the consumer report / investigative consumer report may include, but is not limited to the following areas: verification of social security number, credit reports, current and previous residences, employment history, education background, character references, drug testing, civil and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions, driving records, birth records, and any other public records. Background Screening Consent Please go through below documents Loading documents I have reviewed all the documents Download All Employee Info WOTC Questionnaire Sign and Submit I-9 Form Emergency Contact NYS Urban Youth Program W-4 Form Payroll and Direct Deposit Form Background Screening Consent Company Policy Upload Documents Yes No Applicant Information Previous Next Form Preview How are you filing? Do you hold more than one job at a time, or are married - filing jointly - and your spouse also works? Claim Dependents Single or Married filing separately Married filing jointly (or Qualifying widow(er)) Head of household Check only if you’re unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual. Do you hold more than one job at a time, or are married - filing jointly - and your spouse also works? Enter the number of qualifying children under age 17 Enter the number of other dependents Total Number of Dependents Total Amount of withholding Add Other Adjustments (Optional) Remove Other Adjustments (Optional) (a) Other income (not from jobs). If you want tax withheld for other income you expect this year that won’t have withholding, enter the amount of other income here. This may include interest, dividends, and retirement income (b) Deductions. If you expect to claim deductions other than the standard deduction and want to reduce your withholding, use the Deductions Worksheet on page 3 and enter the result here (c) Extra withholding. Enter any additional tax you want withheld each pay period Other Adjustments (Optional) If your income will be $200,000 or less ($400,000 or less if married filing jointly)