First Name:_____________ Last Name:___________________ Date of Birth:___________
Social Security #:________________________ Phone #:________________________
Address:_______________________ City:_______________ State:____________ Zip:___________
Answering the following
questions will have no impact on your employment opportunity or any benefits you are receiving,
and is done so on a voluntary basis.
Depending on your answers and if you are hired, your employer may qualify for certain incentives and
tax credits. This form, and all its contents, is strictly confidential and will be used only for
review of federal and state tax credit eligibility. If hired, I hereby authorize the release of any
information from any federal or state Governmental Agency including, SSA, Dept. of Veterans Affairs,
or the Department of Motor Vehicles to determine eligibility for federal or state tax credit programs.
Agree Do not agree
1. Are you under 25 AND have you or any member of your household received Food Stamps during the past 9 months? Yes No
2. Does one of these apply to your AFDC, TANF, TAF or other family welfare benefits:
a-received benefits for a 9-month period within the last 18 months, OR
b-received benefits for an 18-month period since 1997, OR
c-stopped receiving benefits after 1997 due to maximizing of benefits. Yes No
3. Have you completed Vocational Rehab from a state Approved Agency or the Department of Veteran's Affairs in the last 2 years? Yes No
4. Do you have 180 days of active duty in the National Guard, Army, Navy, Air Force, Marines or Coast Guard AND received food stamps for any three-month period within the last 15 months? Yes No
5. Within the past 12 months have you had a felony conviction, been released from prison, or paroled for a felony conviction or are you on work release? Yes No
6. Have you received Supplemental Security Income Benefits (Disability) within the past 60 days? Yes No
7. Are you or your spouse a Native American Indian registered under a tribe of Native Americans? Yes No
8. On August 28, 2005, did you live in the core disaster area created by Hurricane Katrina in
AL, LA, or MS and were you displaced as a result of Hurricane Katrina? Yes No
9. On August 28, 2005, did you live in the core disaster area created by Hurricane Katrina in
AL, LA, or MS and are you applying for a job or being hired by a company located in the core
disaster area created by Hurricane Katrina? Yes No