Six months prior to hire, were
you enrolled in any of the following programs?
Please check all boxes that apply to you.
WIA
(Workforce Investment Act)
WOTC
(Work Opportunity Tax Credit)
CalWORKS
(previously known as GAIN)
I
am a member of a federally recognized Native American Tribe.
I
was discharged from the United States Military service within
the last 48 months.
I
served in the United States Military between 8/05/64 and 5/07/75.
Within
six months prior to hire, I was employed as a migrant worker.
I
was laid off from my job and return is unlikely.
I
was unemployed due to plant closure or massive layoff.
I
have been unemployed for at least 15 of the past 25 weeks prior
to hire.
I
have been convicted of a crime and/or have been on probation.
I
am 55 years of age or older.
I
have exhausted all of my Unemployment Insurance.
6 months prior to hiring were you receiving
any of the following?
Please check all boxes that apply to you.
AFDC
/ Food Stamps
General
Assistance
State
Disability
Supplemental
Security Income (SSI)
Refugee
Cash Assistance
Did
any family members in your household receive any of the benefits
listed above?
Please choose the number of family members
living in your household 6 months prior to hire:
Please choose the amount closest to your total
household income 6 months prior to hire:
Participation in this tax credit program is voluntary.
If you have checked any of the boxes, you are potentially Enterprise
Zone qualified. You must provide proof of eligibility before
a tax credit can be issued. By sending this form you are acknowledging
your participation in this program is voluntary and the answers
you have given are true and correct to the best of your knowledge.
Also, you give the Enterprise Zone representative your authorization
to verify any information provided on this form within the next
6 months. |
