WORK OPPORTUNITY TAX CREDIT PACKAGE

AUT

EMPLOYEE INSTRUCTIONS

Thank you for completing the tax credit screening portion of your application
process. We have determined that your prospective new employer may qualify for
the Work Opportunity Tax Credit program. There will be several tax credit forms that
will be signed electronically after you create your password which will include the
8850 and authorization for release form.

We appreciate your assistance.

____________________________________________________________________

AUTHORIZATION FOR DISCLOSURE OF INFORMATION

I hereby authorize my employer or employer representative to obtain information from
my records to determine my eligibility for the Work Opportunity Tax Credit Program. I
also authorize the appropriate agency to release the requested information from my
records to my employer or employer representative; including Social Security
Administration for a TPQY printout.

Employee Name: Maria Osorio

SSN:

Employee Signature:

Date:



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Form Approved
OMB No. 0960-0566

Social Security Administration

Consent for Release of Information

TO: Social Security Administration
Maria Osorio

1022

Name

Date of Birth

Social Security Number

I authorize the Social Security Administration to release information or records about

me to:
NAME

ADDRESS
7130 Minstrel Way
Suite L100

MAXIMUS

Columbia, MD 21045
I want this information released because:

(There may be a charge for releasing information.)

Please release the following information:

Social Security Number

Identifying information (includes date and place of birth, parents' names)
Monthly Social Security benefit amount
Monthly Supplemental Security Income payment amount
Information about benefits/payments I received from
to
Information about my Medicare claim/coverage from
to
(specify)
Medical records
Record(s) from my file (specify)
Other (specify) TPQY PRINTOUT

I am the individual to whom the information/record applies or that person's

parent (if a minor) or legal guardian. I know that if I make any representation
which I know is false to obtain information from Social Security records, I could
be punished by a fine or imprisonment or both.
Signature:

(Show signatures, names, and addresses of two people if signed by mark.)

Date:
Form SSA-3288 (5-2007) EF (5-2007)

Relationship: