PRINT FORM CLEAR FORM
   85-199
   (3-17)

Texas Enterprise Zone – Post-Employment Employee Certification Survey
Texas Comptroller of Public Accounts
The Comptroller of Public Accounts distributes this survey for the Texas Economic Development Council to report the number of jobs we have created and 
the economic characteristics of our employees. Completing this survey is voluntary and your responses are confidential.
This survey is used to obtain information from you as an employee of  _____________________________________________, located in the
city of ____________________ , Texas.

   Employee Name  ________________________________________________  Employment Date  ___________________________________   
   Employee Payroll ID#  ______________  Home Address, Street,City, Zip Code  __________________________________________________

Please check all boxes that apply to you:
 I was unemployed for at least three months, from  __________    to_________ , before being employed with  _______________________________ .
 Last employer name  _______________________________________ .

 I received public assistance benefits before being employed by  ________________________________________ , including welfare payments,
 Women, Infants and Children (WIC) or food stamps (food stamps must be received by you, not an immediate family member).
 List name of public assistance program(s):  ___________________________________  Benefit ID#:  ______________

 I am a low-income individual, as defined by Section 101, Workforce Investment Act of 1998 (29 U.S.C. Section 2801(25)).

 I am an individual with a disability as defined by 29 U.S.C. Section 705(20)(A).  (Individuals MUST be certified by an authorized agency or doctor.)
 Authorized agency name  ___________________________   Physician name __________________  Physician phone number  _______________

 I am an inmate imprisoned by order of a court, whether actually imprisoned in a facility operated by, or under contract with, the Correctional Institutions
 Division of the Texas Department of Criminal Justice or under the supervision or custody of that agency’s Paroles Division.

 I, or an immediate family member, received Supplemental Security Income (SSI) or Temporary Assistance for Needy Families (TANF) payments.
 List the name of the program(s):  ______________________________ Program(s) ID#:  _____________.

 I meet the current low income or moderate income limits (reference below) developed under Section 8, United States Housing Act of 1937 (42 U.S.C.
 Section 1437f et seq.) for  ______________________ County, Texas.

 Enter the year of HUD income level for this certification   _______________________ .
 You can access HUD Program Income Limits (Section 8, Section 221(d)(3) BMIR, Section 235 and Section 236) to find the specific income 
 limits data set to use based on the year employee was hired via this link: www.huduser.org/portal/datasets/il.html.
 I am a member of a family of  _____ whose total family income was (subtotal of the amounts below) $ _____________ before I was hired at or below  
 the income level indicated from the HUD Program. Income Limits referenced immediately above:
 You $ __________
 Your spouse $ ____________  
 All dependents $ _____________
 Family members living with you $ ____________
 Total family income (subtotal of all the amounts above) $ ___________

 I was under the permanent managing conservatorship of the Department of Family and Protective Services on the day before my 18th birthday.

 I am entering the workforce after being confined in a facility operated by, or under contract with, the Texas Department of Criminal Justice for the
 imprisonment of individuals convicted of felonies other than state jail felonies.

 I have been released by the Texas Youth Commission and am on parole, if state law provides for such a person to be on parole.

 None of the above applies to me.

Certification
I declare and affirm under penalty of perjury that the statements made herein are true and correct to the best of my 
knowledge, information and belief.
____________________________                        ________________
Employee Name Print                                Date
____________________________                        ________________
Employee Signature                                 Date