WOTC

Leave this field empty

Warning! DO NOT CHANGE the structure of the tables below. Do not change the table ID or add, delete, or rearrange the columns.

Original Field Names

Info. The following is a list of fields where the field label will appear when the toggle button is clicked. These are the original field names from the web form. We are retaining the original form names to avoid any future issues.

EMPLOYERUUID

applicant_id

Email Address

FName

LName

PhoneNumber

Applicant Address

Applicant City

Applicant State1

Applicant Zip

County

Date of Birth NEW

Your SSN

IDtype

Applicant State

Govt_id

Question1

q3a

Recipient_name3

Recipient_address3

q3acaseid

q3b

q3vetrancomp

q3c

q3vetranDischarged

Discharge Papers

q4b

Recipient_name4

Recipient_address_4

q4CaseID

q5a

5agencyContactname

5ContactPhoneNumber

q5b

q6a

q6b

q6c

Recipient_name_6

Recipient_address_6

q6caseID

Conviction_date

Conviction_release_date

Fed_state

7correctionsID

7NameofFacility

7City

7State

7dateProbationbegan

7ParoleOfficeName

7ParolePhoneName

Felony Records

8SSIContactName

8SSIContactPhoneNumber

q9a

COMPLETEPDF

Renamed Fields on API

Info. We understand that the API call and the original fields have different names. The table below will help you map the API object keys to the field names, allowing the toggle button to display the API object keys instead of the original field names.

EMPLOYERUUID	employerUUID
applicant_id	ApplicantID
Email Address	emailAddress
FName	FName
Mi	Mi
LName	LName
PhoneNumber	PhoneNumber
Applicant Address	Applicant Address
Applicant City	Applicant City
Applicant State1	Applicant State
Applicant Zip	Applicant Zip
County	County
Date of Birth NEW	DOB
Your SSN	SSN
IDtype	IDtype
Applicant State	Applicant State ID Issued
Govt_id	Identification Number
Question1	q1
q2	q2
q3	q3
q3a	q3a
Recipient_name3	q3a Recipient Name
Recipient_address3	q3a Recipient Address
q3acaseid	q3a Recipient CaseID
q3b	q3b
q3vetrancomp	q3b Veteran Comp
q3vetranDischarged	q3b Veteran Discharged
q3c	q3c
q3vetranDischarged	q3 Discharge Papers
Discharge Papers	q3 Discharge Papers_filename
q4	q4
q4b	q4b
Recipient_name4	q4b Recipient Name
Recipient_address_4	q4b Recipient CityState
q4CaseID	q4b CaseID
q5	q5
q5a	q5a
5agencyContactname	q5b Agency Contact Name
5ContactPhoneNumber	q5b Contact Phone Number
q5b	q5b
q6	q6
q6a	q6a
q6b	q6b
q6c	q6c
Recipient_name_6	q6c Recipient Name
Recipient_address_6	q6c Recipient CityState
q6caseID	q6c CaseID
q7	q7
Conviction_date	q7 Conviction Date
Conviction_release_date	q7 Conviction Release Date
Fed_state	q7 Federal or State
7correctionsID	q7 Corrections ID
7NameofFacility	q7 Facility Name
7City	q7 City
7State	7State
7dateProbationbegan	q7 Date Probation Began
7ParoleOfficeName	q7 Parole Office Name
7ParolePhoneName	q7 Parole Phone Number
Felony Records	q7 Felony Records
Felony Records	q7 Felony Records_filename
q8	q8
8SSIContactName	q8 Contact Name
8SSIContactPhoneNumber	q8 Contact Phone Number
q9a	q9
COMPLETEPDF	COMPLETEPDF
COMPLETEPDF	COMPLETEPDF_filename

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{IF [field_1554601422120_241] <> '' THEN} [field_1554601422120_241] {ENDIF}{IF [field_1554601422120_241] = '' THEN}Please take a moment to complete the WOTC Tax Credit Questionnaire.

Please do not close the browser until the form is successfully completed and signed.

Click the button below to begin. Thank you!{ENDIF}

Enter your Email and Choose your Language to get Started

signingQueryString

threeDaysAgo

DuplicateCheck

EsignStatus

DuplicateCheckFlag

English

Spanish

Get Started Back

Loading Documents for Signature.. please wait...

Get Started

sourceID

V2PDFSProcessed

DisableRESP

isViaAPI

enableFieldTips

DirectEmailSent

ReminderEmail

Enter a Value

MJAEMAIL

WasFormSubmitted

Click Me

langSwap

Start Page Message

start page

spanishformview

confirmationcode

applicant_id

ApplicantID

WebHookURL

UserId

privatelabelId

uuid

taskId

user_id

hw_instance_id

company_id

uid

sandbox

return_url

akkenCompKey

akkenMod

akkenResId

akkenUser

employee_id

debug

Debugging Values

Employer Lookup

debug

Allow Duplicates

EMPLOYERUUID

employer_StaticRedirectURL

employer_RedirectOption

employer_base_redirectURL

employer_final_redirectURL

GetReturnURLFromWOTC

EmployerID

employer_dissalowDuplicates

logo

logoFullPath

Custom Post Submission Page

Ineligible Page Confirmation Message

Post Success Signing Confirmation Message

Confirmation Code Opening Text

Confirmation Closing Text

employerUseConfirmationCode

employerUseStaticConfirmationCode

employerStaticConfirmationCode

employer_enforceQ1

employer_enforceQ2

Employers Name

Phone

Employer Telephone Number Area Code

Employer Telephone Number First 3

Employer Telephone Number Last 4

EIN

Address

full address

City

State

Zip/Postal Code

WOTCIntroText

WOTCQuestion1Formatted

EmployerKIEN

KYTAXIDpart1

KYTAXIDpart2

EmployerFedTaxID

FedTaxpart1

FedTaxpart2

Debug

Employers Name

Phone

Address

Contact full address

Contact Combined Address

City

State

Zip/Postal Code

WOTC Questionnaire - [field150]
Work Opportunity Tax Credit

The following questions help determine eligibility for the Work Opportunity Tax Credit (WOTC). Please select any of the following that apply to you:

Core Questions

Veteran

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

SNAP

Have you or any member of your family received food stamps or SNAP (Supplemental Nutritional Assistance Program) during the past 6 months?

Referred

Were you referred by a rehabilitation agency approved by the state, an employment network under the Ticket to Work program, or the Department of Veterans Affairs?

TANF

Have you or any member of your family received TANF (Temporary Assistance for Needy Families) in the past 2 years? This may also be known as Welfare benefits.

Felony

Have you been convicted of a felony or released from prison for a felony during the past year?

SSI

Have you received SSI (supplemental security income) benefits during the past 60 days?

Unemployed

Have you been unemployed at least 27 consecutive weeks?

INVALID

None of the Above Apply

Q5 and Q2 on 8850

Yes

SNAP

Yes

TANF

Yes

1. Have you ever been employed by [First Name]?

Yes

2. Are you between the ages of 18-39?

Yes

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

Yes

7. In the past year have you been convicted of a felony or released from prison for a felony?

Yes

8. Did you receive Supplemental Security Income (SSI) benefits for any month ending within the last 60 days?

Yes

9. Were you in a period of unemployment that is at least 27 consecutive weeks, and for all or part of that period, were you receiving unemployment compensation?

Yes

Did you receive unemployment compensation at any time during that time period

Yes

Next Back

WOTC Questionnaire - [field150]
Work Opportunity Tax Credit

Based upon your previous responses please answer the following questions:

Veteran Questions

Are you a member of a family that received Supplemental Nutritional Assistance Program (SNAP) benefits (food stamps) for at least a 3-month period during the last 15 months?

Are you a Veteran entitled to compensation for a service-connected disability and were discharged or released from active duty during the past year?

Were you unemployed for a period totaling at least 4 weeks but less than 6 months during the past year?

Were unemployed for a combined period of at least 6 months during the past year?

Are you a veteran entitled to compensation for a service-connected disability and have been unemployed for at least 6 months during the past year?

Please provide the following details about the SNAP benefits

Please provide name of primary recipient

City and State where benefits were received

Please provide Case ID Number

Enter a Value

Are you a member of a family that received Supplemental Nutritional Assistance Program (SNAP) benefits (food stamps) for at least a 3-month period during the last 15 months?

Yes

Were you unemployed for a combined period of at least 6 months during the past year?

Yes

Were you unemployed for a period totaling at least 4 weeks but less than 6 months during the past year?

Yes

Are you a Veteran entitled to compensation for a service-connected disability?

Yes

Were you discharged or released from active duty within 1 year before you were hired?

Yes

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WOTC Questionnaire - [field150]
Work Opportunity Tax Credit

Based upon your previous responses please answer the following questions:

SNAP Questions

Have you or a member of your family received SNAP benefits (food stamps) for the past 6 months?

Have you or a member of your family received SNAP benefits (food stamps) for at least 3 of the past 5 months?

None of the Above Apply

4. Are you a member of a family that received Supplemental Nutritional Assistance Program SNAP benefits (food stamps) for the last 6 months?

Yes

OR, received SNAP benefits (food stamps) for at least a 3-month period within the last 5 months, but is no longer receiving them?

Yes

Please provide name of recipient and details

Please provide name of recipient

City & State where benefits were received

Please provide Case ID Number

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WOTC Questionnaire - [field150]
Work Opportunity Tax Credit

Based upon your previous responses please answer the following questions:

REFERRED Questions

Were you referred here by a Rehabilitation agency approved by the State?

Were you referred here by an Employment Network under the Ticket to Work Program?

Were you referred here by the Department of Veterans Affairs?

None of the Above Apply

Please provide Vocational Rehabilitation Agency Contact

Agency Contact Name

Contact Phone Number

5. Were you referred to an employer by a Rehabilitation Agency approved by the State?

Yes

OR, by an Employment Network under the Ticket to Work Program?

Yes

OR, by the Department of Veterans Affairs?

Yes

Next Back

WOTC Questionnaire - [field150]
Work Opportunity Tax Credit

Based upon your previous responses please answer the following questions:

TANF Questions

Are you a member of a family that has received assistance from Temporary Assistance for Needy Families (TANF) for any 9 months during the past 18 months (maybe also be known as Welfare benefits)?

Are you a member of a family that received TANF payments for at least the past 18 months?

Are you a member of a family that received TANF payments for any 18 months during the past 2 years?

Are you a member of a family that stopped being eligible for TANF payments during the past 2 years because federal or state law limited the maximum time those payments could be made?

None of the Above Apply

TANF Eligible

6. Are you a member of a family that received Temporary Assistance to Needy Families (TANF) payments for at least the last 18 months?

Yes

OR, are you a member of a family that received TANF payments for any 18 months beginning after August 5, 1997?

Yes

OR, did your family stop being eligible for TANF payments during the last 2 years because Federal or State law limited the maximum time for payments?

Yes

Are you a member of a family that received TANF for any 9 months during the last 18 months?

Yes

If you are not the primary TANF benefits recipient, please provide the name of the recipient:

Please provide name of recipient

City/State where benefits were received

Please provide Case ID Number

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WOTC Questionnaire - [field150]
Work Opportunity Tax Credit

Based upon your previous responses please answer the following questions:

Date of conviction

Date of release:

Was this a Federal or a State conviction?

Which State

Correction Institution Records Number

Name of Facility

Facility City

Facility State

Date Probabtion Began

Please provide name of Parole Officer

Telephone Number of Parole Officer

Next Back

WOTC Questionnaire - [field150]
Work Opportunity Tax Credit

Based upon your previous responses please answer the following questions:

Unemployed Questions

I have received unemployment compensation for all or part of that period.

I have not received unemployment compensation during that period.

notReceivedUnemployComp

Additional Details

New Hire Name

Your SSN

State(s) unemployment compensation was received

SSN_Last4_1

SSN_Last4_2

SSN_Last4_3

SSN_Last4_4

Employer Name

EIN

EIN_Last4_1

EIN_Last4_2

EIN_Last4_3

EIN_Last4_4

Please check all the statements that apply to you and provide all requested dates.

I have been in a period of unemployment since

ConfirmDeclarationDate

I make this declaration on the day I completed IRS Form 8850 (next)

ConfirmReceivingCOMP

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

ConfirmLongUEMP

I declare that I was in a period of unemployment that is at least 27 consecutive weeks and for all or part of that period I received unemployment compensation.

PDF File

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signatureflag

KY Status

KY Processed

NYYJ Status

NYYJ Processed

TANF Processed

TANF Status

includeKTC

ApplMI

NYYJ Eligible

NYYJ

TANF

postResult

EZ Only

true

Status

Admin Comments

Commentedby

Was Emailed Agreement

form8850_Chk_box2

form8850_Chk_box3

form8850_Chk_box4

form8850_Chk_box5

form8850_Chk_box6

form8850_Chk_box7

includeLongTermUnemploymentPDF

Passed

IsQuestion1Valid

IsQuestion2Valid

OtherQuestionsValid

Three2Eight

Question9Valid

UnderAgeOverride

isFinal

WOTC Questionnaire - [field150]
Work Opportunity Tax Credit

General Information

You're almost done! Please answer a couple more questions and click continue to complete the process.

First Name

Middle Initial

Last Name

Appl_name

Phone Number

Address

Applicant Street Number

Applicant Suite

Applicant Street

Street address where you live

8850 Street Address

Applicant Full Address

City or town, state, and ZIP code

City

State

Confirm Employer Name

Zip/Postal Code

County

Date Format: Enter your Birthdate in this format MONTH/DAY/YEAR (e.g 04/25/1977)

Date of Birth (Enter as MM/DD/YYYY)

Date of Birth

DOB

CalculatedAge

Your SSN

SSNLAST4

Type of ID (Please Select One):

	Drivers License
	State ID
	Birth Certificate
	US Passport
	Federal/State Gov ID
	School I.D. Number

In which State was your ID issued?

Identification Number:

Identification Number can be any PHOTO ID used on the I-9 (Examples: Drivers License, State ID, INS, Passport, etc.)

Branch

Which location are you applying for work?

employer_city

employer_state

Branch

IMPORTANT! Read the disclaimer below and check the box next to it before clicking continue.

I certify that the information is true and correct to the best of my knowledge. I understand that the information above may be subject to verification. I hereby authorize agencies, organizations, or individuals to release requested information to MJA & Associates. I understand that this information will be used solely for the purpose of qualifying my employer for the Work Opportunity Tax Credit program.

PDF File

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WOTC Questionnaire - [field150]
Work Opportunity Tax Credit

Kentucky Unemployment Tax Credit Program Application

Were you a resident of Kentucky on the hire date?

Yes

Hire Date

Hire Date mm

Hire Date dd

Hire Date yy

Start to Work Date

Start Date mm

Start Date dd

Start Date yy

Your Address on the date you were hired:

Address

City

State

Zip/Postal Code

Were you actively seeking work during the 60 days prior to the hire date above?

Yes

Were you readily available to accept full-time employment during the 60 days prior to the hire date above?

Yes

Do you have an employment history?

Yes

Previous Employment Details #1

Employer Name

Employer Telephone Number

Employer Address

Employer City

Employer State

Employer Zip

Employment Start Date

Employment End Date

Average Hours Worked Per Week

Average Hours Worked Per Month

Employer Address_1

Employer_1_phone_area

Employer_1_phone_first3

Employer_1_phone_last4

Employer_1_employed_mm

Employer_1_employed_dd

Employer_1_employed_yy

Employer_1_employed_to_mm

Employer_1_employed_to_dd

Employer_1_employed_to_yy

Previous Employment Details #2

Employer Name

Employer Address

Employer City

Employer State

Employer Zip

Employer Telephone Number

Employment Start Date

Employment End Date

Average Hours Worked Per Week

Average Hours Worked Per Month

Employer Address_2

Employer_2_phone_area

Employer_2_phone_first3

Employer_2_phone_last4

Employer_2_employed_mm

Employer_2_employed_dd

Employer_2_employed_yy

Employer_2_employed_to_mm

Employer_2_employed_to_dd

Employer_2_employed_to_yy

Previous Employment Details #2

Employer Name

Employer Address

Employer City

Employer State

Employer Zip

Employer Telephone Number

Employment Start Date

Employment End Date

Average Hours Worked Per Week

Average Hours Worked Per Month

Employer Address_3

Employer_3_phone_area

Employer_3_phone_first4

Employer_3_phone_last4

Employer_3_employed_mm

Employer_3_employed_dd

Employer_3_employed_yy

Employer_3_employed_to_mm

Employer_3_employed_to_dd

Employer_3_employed_to_yy

EmployerKIEN

KYTAXIDpart1

KYTAXIDpart2

EmployerFedTaxID

FedTaxpart1

FedTaxpart2

Debug

PDF File

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WOTC Questionnaire - [field150]
Work Opportunity Tax Credit

South Carolina Department of Social Services - Verification Of Receipt Of Temporary Assistance For Needy Families (Tanf) Benefits

TANF

Employee’s Indication Of Receipt Of Benefits
Did you receive a TANF (Temporary Assistance for Needy Families) stipend from the
Department of Social Services for the three months before your hire date?

Consent To Request Verification
For the purpose of my employer claiming a South Carolina Family Independence Income Tax Credit, I hereby grant my employer permission to request verification of my current/former participation in the TANF Program from the Department of Social Services

Yes

Continue Back

PDF File

WOTC Questionnaire - [field150]
Work Opportunity Tax Credit

New York Youth Jobs Program - [field150]

New York Youth Jobs Program: 2025 Youth Certification

I currently live in the town, or city limits, of the following target area, check one:

	Albany
	New Rochelle
	Utica

	Brookhaven
	New York City (5 boroughs)
	White Plains

	Buffalo
	Rochester
	Yonker

	Hempstead
	Schenectady
	Mount Vernon

	Syracuse
	Other Area

Other Area

I am currently attending high school

Yes

I am currently enrolled in a High School Equivalency (HSE) program

Yes

I have working papers

Yes

Are any of the following four statements true?

I am currently unemployed
I was unemployed prior to completing this application.
I do not have enough paid work.
The work I have does not make use of my skills and training

Yes

I am 16 or 17 years old. I have my parent’s or guardian’s permission to submit this application

Yes

Parent/Guardian First name

Parent/Guardian Last name

Parent/Guardian Phone

I am 18 to 24 years old Years Old

Yes

I am currently unemployed, I was unemployed prior to completing this application or I do not have enough paid work or work that is adequate with respect to my skills and training

Yes

I confirm that I currently meet one or more of the youth categories listed below.

Yes

I am over 18 and do not have a high school diploma or a GED/TASC/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 or reduced-cost school lunch.
I was referred here by a rehabilitation agency approved by the state, or an employment network under the Ticket to Work Program.
I have served in jail or prison - or am on probation or parole.
I am pregnant or a parent.
I am homeless.
I am currently or was in foster care or 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.
Another risk factor not identified above

I would like the Department of Labor to contact me by Phone or Email

Phone

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.

Agree

When I check this box and submit this form, I agree to the statement above.

Continue Back

PDF File

WOTC Questionnaire - [field150]
Work Opportunity Tax Credit

Ineligible. Thank you for taking the time to complete our WOTC questionnaire.

Next Back

Agreement Status

Last Agreement Event

Last Agreement Event Description

Last Agreement Event Date

Agreement documentKey

Agreement VersionKey

Agreement ProfileID

Signing URL Query String

Agreement Expiration