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SOS WOTC (Work Opportunity Tax Credit) Survey
Step
1
of
10
10%
Name
(Required)
First
Last
Phone
(Required)
Anticipated Job Start Date
(Required)
MM slash DD slash YYYY
Are you under the age of 40?
(Required)
Yes
No
Date of Birth?
(Required)
MM slash DD slash YYYY
Address Information
Address
(Required)
Street Address
Address Line 2
ZIP Code
Survey Questions
Have you or a family member ever received food stamps or SNAP (Supplemental Nutrition Assistance Program)
(Required)
Yes
Not Sure
No
Food Stamp Recipient Questions
Since you answered YES or NOT SURE to receiving Food Stamp Benefits (Supplemental Nutrition Assistance Program), please answer the following questions:
If YES or NOT SURE, are you currently receiving them?
(Required)
Yes
Not Sure
No
First Name of Primary Recipient, if not you:
Last Name of Primary Recipient, if not you:
In what CITY are/were the benefits being received?
(Required)
In what STATE are/were the benefits being received?
(Required)
Survey Questions
Have you or a family member ever received cash assistance payments such as TANF (Temporary Assistance for Needy Families)?
(Required)
Yes
Not Sure
No
TANF Questions
Since you answered YES or NOT SURE to receiving TANF Benefits, please answer the following questions:
First Name of Primary Recipient, if not you:
Last Name of Primary Recipient, if not you:
In what CITY are/were the benefits being received?
(Required)
In what STATE are/were the benefits being received?
(Required)
Survey Questions
Are you a veteran of the U.S. Armed Forces?
(Required)
Yes
Not Sure
No
Veteran Questions
Since you answered YES or NOT SURE to being a Veteran of the U.S. Armed Forces, please answer the following questions:
What was your discharge date?
(Required)
MM slash DD slash YYYY
Which Branch?
(Required)
Army
Navy
Air Force
Marines
Coast Guard
National Guard
During the last year, have you been unemployed for any period of time?
(Required)
No
Not sure
1-2 Months
3-5 Months
6 Months or more
Are you entitled to compensation for a service-connected disability?
(Required)
Yes
Not Sure
No
Survey Questions
Were you receiving Non-Retirement Based Supplemental Security Income (SSI) from the SSA prior to accepting this job?
(Required)
Yes
Not Sure
No
Survey Questions
Have you ever been convicted of a felony?
(Required)
Yes
Not Sure
No
Felony Questions
Since you answered YES or NOT SURE to being convicted of a felony, please answer the following questions:
Date of Conviction
(Required)
MM slash DD slash YYYY
Date of Release (if applicable)
MM slash DD slash YYYY
What type of Conviction?
(Required)
Federal Conviction
State Conviction
Not Sure
In what STATE was the conviction?
(Required)
Survey Questions
Before today, have you been unemployed in the last 27 weeks?
(Required)
Yes
Not Sure
No
Unemployment Questions
Since you answered YES or NOT SURE to being unemployed, please answer the following questions:
Did you receive unemployment benefits?
(Required)
Yes
Not Sure
No
In what STATE did you receive those benefits?
(Required)
Survey Questions
Are you or your spouse a member of a Native American Tribe?
(Required)
Yes
Not Sure
No
Native American Tribe Questions
Since you answered YES or NOT SURE to being unemployed, please answer the following questions:
What is the name of your tribe?
(Required)
Certificate of Degree of Indian Blood #
Survey Questions
Were you referred to this employer by any of the following?
(Required)
Vocational Rehabilitation
Ticket or Work Program
Department of Veteran Affairs
None
