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Revised WOTC forms for veteran groups
Summary ETA issued revised Work Opportunity Tax Credit forms and instructions to implement veteran target group changes in the VOW to Hire Heroes Act and other program changes. It attached six forms and instructions; later TEGL 34-12 updated WOTC forms. ETA now labels this advisory Canceled.
Document
Federal guidance
Agency
U.S. Department of Labor, Employment and Training Administration (ETA)
Document number
TEGL No. 4-12
Date issued
July 31, 2012
Status
Withdrawn
ETA lists this advisory Canceled as of 2026-10-24; its PDF prints Expiration Date: Continuing and Rescissions: None. It implements VOW Act forms later updated by TEGL 34-12.
Status last verified October 24, 2026
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Accessible letter PDF: https://www.dol.gov/sites/dolgov/files/ETA/advisories/TEGL/2012/TEGL_4_12_Acc.pdf
CLASSIFICATION
EMPLOYMENT AND TRAINING ADMINISTRATION WOTC
ADVISORY SYSTEM CORRESPONDENCE SYMBOL
U.S. DEPARTMENT OF LABOR OWI
Washington, D.C. 20210 DATE
July 31, 2012
ADVISORY: TRAINING AND EMPLOYMENT GUIDANCE LETTER NO. 4-12
TO: ALL STATE WORKFORCE AGENCIES
ALL STATE WORKFORCE LIAISONS
FROM: JANE OATES /s/
Assistant Secretary
SUBJECT: Revised Forms for the Work Opportunity Tax Credit (WOTC) Program for
Implementation of the Veterans Opportunity to Work to Hire Heroes Act of 2011
(VOW Act) Provisions and Other Program Changes
l. Purpose. To transmit revised WOTC forms and instructions, which were updated to reflect
the amendments and new provisions in the VOW Act and other legislative changes to the
WOTC program.
2. References.
• Section 261 of the VOW to Hire Heroes Act of 2011, (title II of Pub. L.
112-56);
• The American Recovery and Reinvestment Act (Recovery Act) of 2009 (Pub. L. 111-5);
• Internal Revenue Code of 1986, Section 51, as amended;
• Internal Revenue Service (IRS) Notices 2009-69 (August 31, 2009) and 2009-28, 2009-
24 I.R.B 1082 (June 15, 2009);
• IRS Notice 2012-13, Part III – Administrative, Procedural, and Miscellaneous, Section 51
– Work Opportunity Tax Credit;
• Section 52 – Special Rules;
• Section 3111(e) Credit for Employment of Qualified Veterans (February 9, 2012);
• Training Employment Guidance Letter (TEGL) No. 30-11, Information and Guidance on
the Work Opportunity Tax Credit Provisions Introduced by the Veterans Opportunity to
Work (VOW) to Hire Heroes Act of 2011, and IRS Guidance on Submission of Form 8850
(May 24, 2012);
• TEGL No. 15-11, Work Opportunity Tax Credit (WOTC) Procedural Guidance During
Authorization Lapse for Non-veteran WOTC Target Groups (January 12, 2012);
• TEGL No. 11-08, Extension of the Information Collection for the Consolidated Work
Opportunity Tax Credit Program: Revised Reporting and Processing Forms (February
19, 2009);
• TEGL No. 11-08, Change 1, Extension Period Granted to the State Workforce Agencies
and Employers for the Uninterrupted Use of All 2007 and 2008 Work Opportunity Tax
Credit (WOTC) Program Processing Forms (March 25, 2009); and
RESCISSIONS EXPIRATION DATE
None Continuing
• ETA Handbook No. 408, November 2002, Third Edition (the Handbook); and
August 2009 Addendum to the Handbook.
3. Background. The Recovery Act added two target groups to the WOTC program –
unemployed veterans and disconnected youth. These two target groups expired on December
31, 2010. As a result, TEGL No. 20-10 was issued with program guidance in the event of a
retroactive reauthorization of those target groups. However, enough time has passed without
Congressional activity extending these two groups. Therefore, references to the two
Recovery Act groups have been removed from the existing forms. The Youth Self-
Attestation Form, ETA Form 9154, which was used as verification of eligibility for the
disconnected youth target group, has been discontinued. The Employment and Training
Administration (ETA) will be releasing forthcoming guidance on close out procedures of the
applications for the expired Recovery Act groups.
On November 21, 2011, President Obama signed the VOW Act into law. Section 261 of the
VOW Act, “Returning Heroes and Wounded Warriors Work Opportunity Tax Credit,”
amends and expands the definition of the original Qualified Veteran target group.
Specifically, Section 261 amends the definition of Qualified Veteran by adding two new
unemployed veteran categories and extending the availability of the existing veterans
receiving Supplemental Nutrition Assistance Program (SNAP) and disabled veteran
categories. The VOW Act does not extend the Recovery Act unemployed veteran and
disconnected youth target groups. Guidance regarding eligibility for the veterans amended
and expanded target groups was provided in TEGL No. 30-11 dated May 24, 2012.
The provisions in the VOW Act apply to new employees who began working for an employer
on or after November 22, 2011 and before January 1, 2013. As a result of the provisions in
the VOW Act, the WOTC forms and instructions were revised to reflect current legislative
changes.
Several other changes to the WOTC program became effective on December 31, 2011. On
this date, as outlined in TEGL No. 15-11, the WOTC program’s legislative authority for all
non-veteran target groups expired. However, these target groups remain on the WOTC
forms, in recognition that Congress may pass retroactive reauthorization for the non-veteran
target groups, as has occurred previously throughout the WOTC program’s history. Also,
legislative authorization for Empowerment Zones, which determined eligibility for the
summer youth group, has ended and as a result, the summer youth group is no longer a
WOTC target group, and has been removed from the WOTC forms.
4. Revised Forms and Instructions. ETA has revised the processing, administrative, and
reporting program forms to reflect: 1) removal of all references to the expired Recovery Act
unemployed veteran and disconnected youth target groups, 2) removal of the summer youth
target group, and 3) inclusion of the new VOW Act veteran target group provisions. The
revised forms and accompanying instructions were approved by the Office of Management
and Budget (OMB) through June 30, 2015.
State Workforce Agencies (SWAs) are required to use, without modification, three of the
current five required WOTC reporting, administrative, and processing forms – ETA Form
9058, 9061 and 9062. SWAs are free to design their own formats for the “Employer
Certification” form (ETA Form 9063) and “Verification Results” form (ETA Form 9065) so
long as they include all the information required in the original optional forms.
ETA Form 9058 – Report 1 is used by the SWAs to report program data to ETA on a
quarterly basis via EBSS. ETA Forms 9061, 9062, and 9063 are used by the SWAs and
employers. These forms are critical for the operation of the WOTC program. Form 9061 or
9062 is used by employers to submit certification requests (together with IRS Form 8850) to
SWAs, and contains all the information SWAs need to process those requests consistent
with statutory requirements and the program’s integrity. All SWAs and participating
agencies to which SWAs have delegated responsibility for issuing Conditional Certifications
are required to use the “Conditional Certification” form (ETA Form 9062) without
modification for pre-certifications of certain groups only. Form 9063 is the certification
SWAs issue to employers or their representatives upon a positive target group eligibility
determination. If audited, employers must provide this certification to the IRS. Finally,
ETA Form 9065 is an internal worksheet SWAs use in conducting their quarterly internal
audits.
Revisions to the reporting, processing and administrative forms are described in detail in the
following paragraphs. The revision date on the bottom of each form has been changed to
“June 2012” and the reference to “Division of Adult Services” in the Paperwork Reduction
Act paragraph was removed and replaced with “Division of National Programs, Tools and
Technical Assistance,” the name of the new division responsible for the WOTC program.
ETA Form 9058 – Report 1, Certification Workload and Characteristic of Certified
Individuals and its instructions were revised as follows:
Section 51 of the Internal Revenue Code and the 1996 original target group legislative alpha
designation for a Qualified Veteran is “B.” To distinguish among the amended veteran
group and the newly introduced veteran categories, and provide the SWAs with a uniform
system to report the number of certifications or denials issued to each new group, the “B”
designation is being used followed by alpha-numeric identifiers. The current Boxes 2a and
2b (in Column I) “By WOTC Target Group” under Part II. “CHARACTERISITICS OF
CERTIFIED INDIVIDUALS”) have been replaced with the following five Boxes:
o Box 2Ba. Added (V) after “Veteran receiving SNAP benefits,”
o Box 2Bb. Added (DV) After “Disabled Veteran,”
o Added Box 2Bc. and titled it “DV unemployed for 6 months,”
o Added Box 2Bd. and titled it “V unemployed for 4 weeks,” and
o Added Box 2Be. and titled it “V unemployed for 6 months”.
Boxes 3 and 4 did not change. Box 3. still collects Ex-felon data and Box 4. still collects
Designated Community Resident data. Box 6. Summer Youth was deleted reflecting the
expiration of legislative authority for Empowerment Zones on December 31, 2011. Box 8.
Unemployed Veteran and Box 9. Disconnected Youth, the two expired Recovery Act target
groups, were deleted.
The rest of the target groups boxes were renumbered as follows:
o Boxes 5a. and 5b. remain as Voc. Rehab Referral and Ticket Holder respectively,
o Box 6. became SNAP Recipient,
o Box 7. became SSI Recipient,
o Box 8. became Long-Term TANF,
o Box 9. became TOTAL (For QTR.), and
o Box 10. became TOTAL (YTD).
Changes were also made to the instructions for ETA Form 9058 to reflect these updates.
Note. SWAs must accept the type of documentation indicated in the revised ETA Form
9061 and its instructions and in TEGL 30-11, issued on May 24, 2012, and may not require
additional documentation from employers and/or representatives that sets a higher standard
of proof of eligibility.
ETA Form 9061, Individual Characteristics Form and Its Instructions were revised as
follows:
1) Provided the appropriate documentary evidence required for the two new unemployed
veteran groups’ eligibility determination;
2) Added questions to Boxes 20 and 21 that identify the two new unemployed veteran
categories;
3) Removed reference to Empowerment Zone in Box 18, indicating that summer youth is no
longer a target group due to expiration of the Empowerment Zones;
4) Deleted instructions for the two expired Recovery Act groups in Boxes 20 and 21; and
5) Added a new form of documentary evidence for Box 13 for service-disconnected
disability, which clarifies and discontinues the use of Form Letter 21-802 once issued
by Department of Veteran Affairs, and which is no longer available.
ETA Form 9062, Conditional Certification, and its Instructions were revised as follows:
1) Former target group references were deleted and all extended and new veteran categories
were added to Box 13 (formerly Box 13a);
2) Box 13b, containing references to the two expired Recovery Act groups, was eliminated;
3) The “Note to Employer” was updated by adding a sentence explaining IRS’s updated
filing date requirements, the beginning and end of the Relief Period and information
when the Relief Period date ends and the “28-day timely filing” after employment-start
date requirement begins;
4) Part II. “EMPLOYER DECLARATION,” Sec. 52 was added to the message to the
SWAs; and
5) All boxes beginning with Box 13b were renumbered to reflect all final box changes.
Box 11 was not removed pending a potential extension by Congress of the non-veteran
WOTC target groups.
The revised instructions indicate that all certifications for the veteran categories are
preceded by the original veteran’s target group 1996 statutory designation letter “B.”
Participating agencies and SWAs will check the category that has been determined
eligible and pre-certify eligible requests accordingly.
ETA Form 9063, Employer Certification, and its Instructions were revised by:
1) Deleting all references to the two expired Recovery Act groups in Box 12;
2) Replacing them with the extended and new veteran categories in the same Box 12;
3) Updating the information under Part C. “CERTIFICATION”; and
4) Updating the “Comments to Employers” to reflect all VOW Act changes and new
veteran provisions.
The revised instructions indicate that all certifications for the veteran categories are preceded
by the original veteran target group statutory designation letter “B” followed by alpha-
numeric identifiers, matching the changes in ETA Form 9058 – Report 1, to help the SWAs
differentiate among the different veteran categories certified and facilitate reporting and
communication between SWAs and employers or their representatives. SWAs will check
the veteran group or category that has been determined eligible and certified in Box 12.
ETA Form 9065, Agency Declaration of Verification Results – Work Opportunity Tax
Credit, now “Audit Summary Worksheet” is an optional ETA form for SWAs’ internal use
in recording the results of verification activities conducted by the SWAs. This form does
not require revisions at this time (except updating the expiration and revision dates and
changing the name of the ETA division, as mentioned above). This is no longer a required
form to be submitted to ETA. The form’s design and format is optional and states can
change both the design and/or format. If the SWAs elect to use an alternative form to record
verification results, the alternative form must contain the information that appears in the
optional ETA form.
5. Transition Period for State Workforce Agencies (SWAs) and Employers. SWAs,
participating agencies, employers, and their representatives are required to start using the
revised OMB-approved “June 2012” version of the ETA Forms. Specifically, ETA Forms
9061 and 9062 must be used to request certifications for new employees 90 days following
the publication of this TEGL. After that date, SWAs should not accept other versions of
ETA Form 9061 or Form 9062. During the 90-day transition period, SWAs may continue
using earlier versions of Forms 9061 and 9062.
SWAs are required to report all program workload processing data using the revised ETA
Form 9058 - Report 1 beginning with the report for the third quarter (Q3) of Fiscal Year
2012. SWAs are being granted an extension of the reporting deadline, August 15, 2012, for
this quarter. Therefore, SWAs now must report all Q3 program data by September 19, 2012.
This extension provides ETA the time necessary to finalize updates and changes to the
electronic ETA Form 9058 in EBSS, and for SWAs to prepare their quarterly report utilizing
the revised form. SWAs will be notified by ETA regional WOTC coordinators when the
electronic ETA Form 9058 has been updated and states can submit their reports into EBSS.
6. Reporting for Expired Non-Veteran Target Groups. As stated above, the WOTC
program’s legislative authority for all non-veteran target groups expired on December 31,
2011. TEGL No. 15-11 instructs SWAs to accept applications (certification requests) in
anticipation of a potential retroactive reauthorization, but to hold off on processing the
requests pending further legislative action and guidance from ETA. During this hiatus
period, SWAs should not report certification requests for any of the non-veteran target
groups received after December 31, 2011, for any quarter, on ETA Form 9058 – Report
1 until ETA issues further guidance.
7. Paperwork Reduction Act Notice and Reporting Authority. WOTC forms and
instructions are approved according to the Paperwork Reduction Act of 1995 (PRA), under
OMB Control Number 1205-0371. This authority is effective through June 30, 2015.
According to the PRA, no persons are required to respond to a collection of information
unless such collection displays a valid OMB control number. The Department notes that a
Federal agency may not conduct or sponsor a collection of information, nor is the public
required to respond to a collection of information unless it is approved by OMB under the
PRA, and displays a currently valid OMB control number (44 U.S.C. 3507). Also,
notwithstanding any other provisions of law, no person shall be subject to penalty for failing
to comply with a collection of information if the collection of information does not display a
currently valid OMB control number (44 U.S.C. 3512).
8. IRS Form 8850. The IRS has updated IRS Form 8850, Pre-Screening Notice and
Certification Request for the Work Opportunity Tax Credit, and its instructions to reflect the
provisions introduced by the VOW Act. The updated form and instructions are available at:
www.irs.gov/form8850. All employers and third parties serving under contract as an
employer’s representative, for purposes of the employer's participation in the WOTC
program, are required to use the January 2012, OMB cleared IRS Form 8850, as modified
pursuant to IRS Notice 2012-13, to request certifications from the SWAs for their newly
hired veterans. During the current hiatus, employers or their representatives can use the
January 2012 IRS 8850 to submit certification requests for individuals hired as members of
any or all of the expired non-veteran target groups. The submitted certification requests are
subject to a potential retroactive reauthorization by Congress of the program beyond
December 31, 2011. Also, as in the past, older versions of IRS 8850s can be submitted to the
SWAs to request certifications for only the target groups listed on that form.
9. Actions. SWA administrators are requested to:
• Provide this information to all appropriate WOTC program staff, employers and their
representatives, participating agencies and other interested partners; and
• Ensure that the SWAs and participating agencies implement these changes in agreement
with the specific procedural guidance and required dates in this TEGL.
10. Inquiries. Questions regarding this guidance should be directed to the appropriate WOTC
Regional Coordinator listed on the WOTC program Web site at: http://www.doleta.gov/wotc.
11. Attachments.
• ETA Form 9058 – Report 1, Certification Workload and Characteristic of Certified
Individuals
• ETA Form 9061, Individual Characteristics Form
• ETA Form 9062, Conditional Certification
• ETA Form 9063, Employer Certification
• ETA Form 9065, Audit Summary Worksheet
• IRS Form 8850, Pre-Screening Notice and Certification Request for the Work Opportunity
Credit
Attachment 1: https://www.dol.gov/sites/dolgov/files/ETA/advisories/TEGL/2012/TEGL_4_12_Att1.pdf
Certification Workload and Characteristics of Certified Individuals U.S. Department of Labor
Work Opportunity Tax Credit - Report No. 1 Employment and Training Administration
State: Quarter Ending: Persons are not required to respond to this collection of information unless it displays a currently valid OM B control number. Respondents' obligation to reply to these reporting OMB No. 1205-0371
requirements is mandatory (P.L. 104-188). Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing Expiration
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of Information. Send comments regarding Date: June 30, 2015
this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to the U.S. Department of Labor, Employment and Training
Administration, Division of National Programs, Tools, and Technical Assistance, 200 Constitution Ave., NW, Room C-4510, Washington, D.C. 20210 (Paperwork Reduction
Project 1205-0371).
PART I. CERTIFICATION WORKLOAD
CERTIFICATION REQUESTS (System Inputs) CERTIFICATION REQUESTS (System Outputs)
A) Incomplete B) Requests Needing Action C) New Requests D) Total Requests E) Certified Requests F) Denied Requests G) Incomplete H) Requests Needing
Requests to Be Processed Requests Action
PART II. CHARACTERISTICS OF CERTIFIED INDIVIDUALS
(a) No. of CCs (b) No. (a) No. (a) No. (a) No.
I) By WOTC Target Resulting in Certified J) By Occupation Certified J) By Occupation (Cont.) Certified K) By Starting Certified
Group Certifications Individuals Individuals Individuals Hourly Wage Individuals
1. Under Federal
1. IV-A TANF Recipient Name-Code Name-Code Minimum Wage
2Ba. Veteran Receiving 1. Management Occupations – 11 12. Protective Services – 33 2. $7.25 - $8.25
SNAP benefits (V)
2Bb. Disabled Veteran (DV) 13. Food Preparation & Serving – 35
2. Business & Financial Operations – 13 3. $8.26 – $8.99
2Bc. DV Unemployed for 6 14. Bldg. & Grounds Cleaning &
months Maintenance – 37
15. Personal Care & Service - 39
4. $9.00 -$9.99
2Bd. V Unemployed for 4 3. Computer & Mathematical – 15 16. Sales & Related Occupations – 41 5. $10.00 - Higher
weeks
2Be. V Unemployed for 6 4. Architecture & Engineering – 17 17. Office/Administrative Support – 43 6. TOTAL (For Qtr.)
months
3. Ex-Felon 5. Life, Physical & Social Sciences – 19 18. Farming, Fishing & Forestry – 45
4. Designated
Community Resident 6. Community & Social Services – 21 19. Construction & Extraction – 47
5a. Voc. Rehab Referral 7. Legal Occupations – 23 20. Installation/Maintenance/Repair- 49
5b. Ticket Holder 8. Education, Training, & Library – 25 21. Production Occupations – 51
9. Arts, Design, Entertainment, 22. Transportation & Material Moving
6. SNAP Recipient Sports/Media Occupations – 27 Production Occupations – 53
7. SSI Recipient 10. Healthcare Practitioner & Technical – 29 23. Military Specific Occupations – 55
8. Long-term TANF 11. Healthcare Support Occupations – 31
9. TOTAL (For Qtr.)
10. TOTAL (YTD)
24. Name and Title of Responsible Official: 25. Signature Title: 26. Date Signed: 27. Total (For Qtr.)
Page 1 of 5 ETA Form 9058 (Rev. June 2012)
Instructions for Preparing ETA Form 9058, Report 1 –“Certification Workload and Characteristics of
Certified Individuals,” Work Opportunity Tax Credit Report
Introduction. Part I. of this report clarifies and simplifies data reported on certifications issued and
provides state workforce agencies’ (SWAs) workload during each reporting quarter. Part II. continues to
collect data on selected characteristics of certified individuals. Boxes 2Ba through 2Be were added to
collect data from the expanded Veteran groups and provisions introduced by the VOW to Hire Heroes Act
of 2011 (P.L. 112-56). Box 6. Summer Youth was deleted because the legislative authority for HUD’s
urban and USDA’s rural Empowerment Zones (EZs) expired on December 31, 2011 and the statutory
definition for this group requires that the youth must reside in an EZ. Box 7, SNAP Recipient became
number 6 and Boxes 7-13 were renumbered as follows: Box 7. SSI Recipient, Box 8. Long-Term TANF,
Box 9. TOTAL (For QTR.) and Box 10. TOTAL (YTD).
Explanation of VOW to Hire Heroes Act of 2011 Changes. Since 1996, SWAs use the “B” alpha
statutory classification for the Veteran group for verification of and issuing certifications to the “qualified
veteran” group. To distinguish among the current and new veteran categories and provide the SWAs with
a uniform system to report the number of certifications issued by each new group, the “B” classification
has been added and is followed by alpha-numeric identifiers for Veteran Boxes No. 2Ba through 2Be as
follows:
Box 2Ba. Added (V) after “Veteran receiving SNAP benefits,”
Box 2Bb. Added (DV) after “Disabled Veteran”
Added Box 2Bc. and titled it “DV unemployed for 6 months”
Added Box 2Bd. and titled it “V unemployed for 4 weeks”
Added Box 2Be. and titled it “V unemployed for 6 months”
The two WOTC ARRA target groups – Unemployed Veterans and Disconnected Youth – authorized by
the American Recovery and Reinvestment Act (P.L. 111-5) expired on December 31, 2010. These target
groups (formerly Boxes 10 and 11) have been removed.
Background. The purpose of ETA Form 9058 (Updated June 2012) is to provide SWAs with a
standardized e-reporting format, which accurately reflects program activity levels and outcomes under the
Work Opportunity Tax Credit (WOTC). It is important for SWAs to maintain programmatic reporting
procedures that account for each tax request (IRS Form 8850) received and its subsequent outcome
(issuance of a tax certification or denial). A properly completed ETA Form 9058 accurately reflects program
use and the level of any programmatic backlog that may exist. To ensure that the WOTC Program can be
accurately evaluated at the national level, it is critical that all SWAs report in a standardized manner using
the web-based Enterprise Business Service System (EBSS) Tax Credit Reporting System (TCRS).
INSTRUCTIONS FOR COMPLETING THIS FORM:
State. Enter the name of the state submitting ETA Form 9058.
Quarter Ending Period. Enter ending date of the quarter for the reported program data.
Part I. "Certification Workload.” SWAs must identify from Part I, Item F on the previous reporting quarter's
ETA Form 9058 the number of requests (IRS Form 8850s) determined to be incomplete or Needing Action,
as defined below:
(A) Number of Requests Incomplete. Enter the total number of requests (IRS Form 8850s) received by the
SWA prior to the beginning of the current report period, but for which no applicant eligibility determination action
(excluding the 48-hour review) was taken. This total is to be entered into Part I, Item (A) of ETA Form 9058.
(B) Number of Requests Needing Action. Enter the total number of requests (IRS Form 8850s) received by
the SWA prior to the beginning of the current report, but for which no review and total is to be entered into Part I,
Item (B) of recently revised ETA Form 9058.
(C) New Requests. Enter the total number of requests (IRS Form 8850s) received by the SWA during the
current reporting quarter. Some states may have received requests (IRS Form 8850s) that were not
previously recorded and/or reported on any prior quarterly report ETA 9058 for various reasons. It is Important
for the SWA to report all requests (IRS Form 8850s) received. Therefore, any request received outside of the
current reporting quarter, which has not previously been reported, should be included with the number of
requests received during the current reporting period. That total should be entered as the number of "New
Requests". This total is to be entered into Part I, Item (C) of ETA Form 9058.
Page 2 of 5 ETA Form 9058 (Rev. June 2012)
(D) Total Requests to Be Processed. Enter the sum of Items A, B & C. This total represents the
number of requests (IRS Form 8850s) received by the SWA, which are available to be processed. This
total is to be entered under Part I, Item (D) of ETA Form 9058. Note. A denial is a request (IRS Form
8850) determined by the SWA to be ineligible for the WOTC.
(E) Requests Certified. Enter the total number of WOTC certifications issued during the current report period.
(F) Requests Denied. Enter the total number of requests (IRS Form 8850s) denied by the SWA during the
current report period.
Note. A denial is a request (IRS Form 8850) determined by the SWA to be ineligible for the WOTC.
(G) Number of Requests Incomplete. Enter the total number of requests (IRS Form 8850s) received and
reviewed by the SWA, but which the SWA could neither approve nor deny due to such things as, but not
limited to, the need for additional eligibility documentation for which the SWA has made a formal request
to the employer, authorized tax consultant, or other third party entity, ETA Form 9061 not submitted, etc.
Note. This number will also be entered in Part 1, Item A. of the subsequent quarterly report ETA Form
9058.
(H) Number of Requests Needing Action. Enter the number of requests (IRS Form 8850s) received by the
SWA but for which no review and/or action has yet been taken to determine applicant eligibility.
Note. This value will also be entered in Part I, Item B. of the subsequent quarterly report ETA Form 9058.
Part I, Item H is the sum of Item D, minus Item E, minus Item F, minus Item G.
Part I. Completion Formula:
(A +B + C) = D and
D – (E + F + G) = H Same as: Items (A+B+C) = D and (D-E-F-G) = H
Part II. "Characteristics of Certified Individuals by Tax Credit." This part is divided into three
sections (Section I, Section J, and Section K).
Section I reflects the number of requests (IRS Form 8850s) certified by the SWA during the current report period
by WOTC target groups. Section J reflects the number of requests (IRS Form 8850s) certified by the SWA
during the current report period by occupation. Section K reflects the number of requests (IRS Form 8850s)
certified by the SWA during the current report period by starting hourly wage.
Section I.
Section I, Column (a). Enter the total number of certifications, issued by the SWAs, by target group, during the
current report period, which resulted from the issuance of a conditional certification i.e., ETA Form 9062.
Section I, Column (b). Enter the total number of WOTC certifications issued by the SWAs, by target group,
during the current report period.
Section I, Line #1. Enter the total number of WOTC certifications issued by the SWA during the current report
period, for the IV-A TANF group.
Section I, Line #2Ba. Enter the total number of WOTC certifications issued by the SWA during the current
report period, for Veterans receiving SNAP benefits.
Section I, Line #2Bb. Enter the total number of WOTC certifications issued by the SWA during the current
report period, for “Disabled Veterans” receiving compensation for a service-connected disability.
Section I, Line #2Bc. Enter the total number of WOTC certifications issued by the SWA during the current
report period, for Disabled Veterans unemployed for 6 months.
Section I. Line #2Bd. Enter the total number of WOTC certifications issued by the SWA during the current
report period, for Veterans unemployed for at least 4 weeks but less than 6 months.
Section I. Line #2Be. Enter the total number of WOTC certifications issued by the SWA during the current
report period, for Veterans unemployed for at least 6 months.
Section I. Line #3. Enter the total number of WOTC certifications issued by the SWA during the current report
period, for Ex-felons
________________________________________________________________________________________________________________
Page 3 of 5 ETA Form 9058 (Rev. June 2012)
Section I. Line #4. P.L. 110-28 changed the name of the High-Risk Youth to “Designated Community
Residents (DCRs).” Enter the total number of WOTC certifications issued by the SWA during the current
report period, for DCRs.
Section I, Line #5a. Enter the total number of WOTC certifications issued by the SWA during the current
report period, for Vocational Rehabilitation Referrals.
Section I, Line #5b. Enter the total number of WOTC certifications issued by the SWA during the current
report period, for “ticket holders.” (e.g., SSDI, or Voc. Rehab -- formerly called People with Disabilities).
Section I, Line #6. Enter the total number of WOTC certifications issued by the SWA during the current report
period, for SNAP (formerly Food Stamps) recipients.
Section I, Line #7. Enter the total number of WOTC certifications issued by the SWA during the current report
period, for SSI recipients.
Section I, Line #8. Enter the total number of WOTC certifications issued by the SWA during the current report
period, for “Long-term TANF” Recipients.
Section I. Line #9. Enter the sums of columns (a) and (b). Note. The total (For Qtr.) of Part II, Section I, Line
#9, columns (a) & (b) should equal the total entered in Part I. Item E. Requests Certified.
Section I, Line #10. Enter the cumulative federal program Year-to-Date (YTD) totals of columns (a) and (b).
Note. The first quarterly report of the federal program year (October 1-December 31), the totals of Section I,
Line #9 and Line #10 should be the same.
Section J.
Section J, Column (a). Enter the total number of WOTC Certifications issued by the SWA during the current
report period, by occupation. Note: The total for Section J, Column (a), Line #27 is the sum of the column and
must equal the total for Section I, Column (a) & (b) Line # 9.
The occupational data reported in Boxes 1-23 are derived from the job titles reported on ETA Forms 9061 or
9062. To prepare this report, SWAs must use the O*NET job families of occupations and their two-digit
corresponding codes as illustrated in the following table.
O*NET SOC JOB FAMILIES
Name Code Name Code
Food Preparation & Serving
Management Occupations 11 35
Related
Bldg. & Grounds Cleaning &
Business & Financial Operations 13 37
Maintenance
Computer& Mathematical Occupations 15 Personal Care & Service 39
Architecture & Engineering 17 Sales & Related Occupations 41
Office & Administrative
Life, Physical & Social Sciences 19 43
Support
Community & Social Services 21 Farming, Fishing, & Forestry 45
Legal Occupations 23 Construction & Extraction 47
Installation, Maintenance &
Education, Training, & Library 25 49
Repair
Arts, Design, Entertainment, Sports and Media Occupations 27 Production Occupations 51
Transportation & Material
Healthcare Practitioner & Technical 29 53
Moving
Healthcare Support Occupations 31 Military Specific Occupations 55
Protective Service Occupations 33
Page 4 of 5 ETA Form 9058 (Rev. June 2012)
Section K
Section K, Column (a). Enter the total number of WOTC certifications issued by the SWA during the
current report period, by starting hourly wage . Note. The total for Section K, Column (a), Line #6 is the
sum of the column for that quarter and must equal the total for Section I, column (b), Line #9.
Convert as follows:
Unit of Time Calculated Hourly Wage
Day Amount divided by 8
Week Amount divided by 40
Month Amount divided by 172
24. Name and Title of Responsible Official. Enter the name and title of the authorized signatory official.
25. Signature. Enter the signature of the authorized signatory official.
26. Date. Enter the date of the authorized signatory official’s signature.
27. Total (for qtr). Enter the total number of WOTC Certifications issued by the SWA during the current
report period, by occupation. Note. The total for Section J, Column (a), Line #27 is the sum of the
column for this quarter and must equal the total for Section I, column (b), Line #9.
1
According to the Fair Labor Standards Act (FLSA), the federal minimum wage is $7.25 per hour
effective July 24, 2009. Source: Wage and Hour Division at the U.S. Department of Labor.
_____________________________________________________________________________
Page 5 of 5 ETA Form 9058 (Rev. June 2012)
Attachment 2: https://www.dol.gov/sites/dolgov/files/ETA/advisories/TEGL/2012/TEGL_4_12_Att2.pdf
U.S. Department Labor OMB No. 1205-0371
Employment and Training Administration Expiration Date: June 30, 2015
Individual Characteristics Form (ICF)
Work Opportunity Tax Credit
1. Control No. (For Agency use only) 2. Date Received (For Agency Use only)
APPLICANT INFORMATION
(See instructions on reverse)
EMPLOYER INFORMATION
3. Employer Name 4. Employer Address and Telephone 5. Employer Federal ID Number (EIN)
APPLICANT INFORMATION
6. Applicant Name (Last, First, MI) 7. Social Security Number 8. Have you worked for this employer
before? Yes ____ No ____
If YES, enter last date of
employment: ____________
APPLICANT CHARACTERISTICS FOR WOTC TARGET GROUP CERTIFICATION
9. Employment Start Date 10. Starting Wage 11. Position
12. Are you at least age 16, but under age 40? Yes ___ No ___
If YES, enter your date of birth _____________________
13. Are you a Veteran of the U.S. Armed Forces? Yes ___ No ___
If NO, go to Box 14.
If YES, are you a member of a family that received Supplemental Nutrition Assistance
Program (SNAP) benefits (Food Stamps) for at least 3 months during the 15 months
before you were hired? Yes ___ No ___
If YES, enter name of primary recipient _______________________ and
city and state where benefits were received _________________.
OR, are you a veteran entitled to compensation for a service-connected disability? Yes ___ No ___
If YES, were you discharged or released from active duty within a year before you were hired? Yes ___ No ___
OR, were you unemployed for a combined period of at least 6 months (whether or not
consecutive) during the year before you were hired? Yes ___ No ___
14. Are you a member of a family that received Supplemental Nutrition Assistance Program
(SNAP) (formerly Food Stamps) benefits for the 6 months before you were hired? Yes ___ No___
OR, received SNAP benefits for at least a 3-month period within the last 5 months
But you are no longer receiving them? Yes ___ No___
If YES to either question, enter name of primary recipient _____________________ and city
And state where benefits were received _____________________.
15. Were you referred to an employer by a Vocational Rehabilitation Agency approved by
a State? Yes ___ No___
OR, by an Employment Network under the Ticket to Work Program? Yes ___ No___
OR, by the Department of Veterans Affairs? Yes ___ No___
1 ETA Form 9061 – (Rev.June 2012)
16. Are you a member of a family that received TANF assistance for at least the last 18 months
before you were hired? Yes___ No___
OR, are you a member of a family that received TANF benefits for any 18 months beginning
after August 5, 1997, and the earliest 18-month period beginning after August 5, 1997, ended
within 2 years before you were hired? Yes___ No___
OR, did your family stop being eligible for TANF assistance within 2 years before you were hired
because a Federal or state law limited the maximum time those payments could be made? Yes___No___
If NO, are you a member of a family that received TANF assistance for any 9 months during
the 18-month period before you were hired? Yes___No___
If YES, to any question, enter name of primary recipient ________________________ and
the city and state where benefits were received _________________________.
17. Were you convicted of a felony or released from prison after a felony conviction during
the year before you were hired? Yes___No___
If YES, enter date of conviction ________________ and date of release _________________.
Was this a Federal ____ or a State conviction_____? (Check one)
18. Do you live in a Rural Renewal County? Yes__ No __
19. Did you receive Supplemental Security Income (SSI) benefits for any month ending within
60 days before you were hired? Yes__ No__
20. Are you a veteran unemployed for a combined period of at least 6 months (whether or not
consecutive) during the year before you were hired? Yes__ No__
21. Are you a veteran unemployed for a combined period of at least 4 weeks but less than 6 months (whether or not
consecutive) during the year before you were hired? Yes__ No__
22. Sources used to document eligibility: (Employers/Consultants: List all documentation provided or forthcoming. SWAs:
List all documentation used in determining target group eligibility and enter your initials and date when the determination was
made.)
I certify that this information is true and correct to the best of my knowledge. I understand that the
information above may be subject to verification.
23(a). Signature: (See instructions in Box 23.(b) for who signs this 23. (b) Indicate with a mark who 24. Date:
signature block) signed this form:
Employer, Consultant, SWA,
Participating Agency, Applicant, or
Parent/Guardian (if applicant is a
minor)
2 ETA Form 9061 – (Rev.June 2012)
INSTRUCTIONS FOR COMPLETING THE INDIVIDUAL CHARACTERISTICS FORM (ICF), ETA 9061. This form is used together with IRS Form 8850 to
help state workforce agencies (SWAs) determine eligibility for the Work Opportunity Tax Credit (WOTC) Program. The form may be completed, on behalf of
the applicant, by: 1) the employer or employer representative, the SWA, a participating agency, or 2) the applicant directly (if a minor, the parent or guardian
must sign the form) and signed by the individual completing the form. This form is required to be used, without modification, by all employers (or their
representatives) seeking WOTC certification. Every certification request must include an IRS Form 8850 and an ETA Form 9061 or 9062, if a Conditional
Certification was issued to the individual pre-certifying the new hire as “eligible” under the requested target group.
Boxes 1 and 2. SWA. For agency use only.
Boxes 3-5. Employer Information. Enter the name, address including ZIP code, telephone number, and employer Federal ID number (EIN) of the
employer requesting the certification for the WOTC. Do not enter information pertaining to the employer’s representative, if any.
Boxes 6-11. Applicant Information. Enter the applicant’s name and social security number as they appear on the applicant’s social security
card. In Box 8, indicate whether the applicant previously worked for the employer, and if Yes, enter the last date or approximate last
date of employment. This information will help the “48-hour” reviewer to, early in the verification process, eliminate requests for
former employees and to issue denials to these type of requests, or certifications in the case of “qualifying rehires” during valid
“breaks in employment” (see pages III-12 and III-13, Nov. 2002, Third Ed., ETA Handbook 408) during the first year of employment.
Boxes 12-21. Applicant Characteristics. Read questions carefully, answer each question, and provide additional information where requested.
Box 22 Sources to Document Eligibility. The applicant or employer is requested to provide documentary evidence to substantiate the YES answers in
Boxes 12 through 21. List or describe the documentary evidence that is attached to the ICF or that will be provided to the SWA. Indicate in
parentheses next to each document listed whether it is attached (A) or forthcoming (F). Some examples of acceptable documentary evidence are
provided below. A letter from the agency that administers a relevant program may be furnished specifically addressing the question to which the
applicant answered YES. For example, if an applicant answers YES to either question in Box 14 and enters the name of the primary recipient and the
city and state in which the benefits were received, the applicant could provide a letter from the appropriate SNAP (formerly Food Stamp) agency
stating to whom SNAP benefits were paid, the months for which they were paid, and the names of the individuals included on the grant for each
month. SWAs will use this box to document the sources used when verifying target group eligibility, followed by their initials and the date the
determination was completed.
Examples of Documentary Evidence and Collateral Contacts. Employers/Consultants: You may check with
your SWA to find out what other sources you can use to prove target group eligibility. (You are encouraged to provide
copies of documentation or names of collateral contacts for each question for which you answered YES.)
QUESTION 12 QUESTION 17
Birth Certificate Parole Officer’s Name or Statement
Driver’s License Correction Institution Records
School I.D. Card Court Records Extracts
Work Permit
Federal/State/Local Gov’t I.D. QUESTION 18
Copy of Hospital Record of Birth
To determine if a Designated Community Resident lives in
QUESTION 13 a RRC, visit the site: www.usps.com. Click on Find Zip
Code; Enter & Submit Address/Zip Code; Click on
DD-214 or Discharge Papers Mailing Industry Information; Download and Print the
Reserve Unit Contacts Information, then compare the county of the address to
Letter of Separation or other agency documents issued only by the the list in the January 2012 Instructions to IRS 8850.
Department of Veterans Affairs (DVA) on DVA Letterhead
certifying the Veteran has a service-connected disability and QUESTION 19
signed by the individual who verified this information.
SSI Record or Authorization
QUESTIONS 14 & 16 SSI Contact
Evidence of SSI Benefits
TANF/SNAP (Food Stamp) Benefit History
Signed statement from Authorized Individual with specific __________________________
description of the months benefits were received Notes:
Case number identifier 1. Where a Federal/State/Local Gov’t., School I.D. Card, or Work Permit
does not contain age or birth date, another valid document must be obtained to
verify an individual’s age.
QUESTION 15 2. ESPL No. 05-98, dated 3/18/98, officially rescinded the authority to use Form I-9
as proof of age and residence. Therefore, the I-9 is no longer a valid
piece of documentary evidence.
Vocational Rehabilitation Agency Contact
Veterans Administration for Disabled Veterans
Signed letter of separation or related document from
authorized Individual on DVA letter head or agency stamp
with specific description of months benefits were received.
For SWAs: To determine Ticket Holder (TH) eligibility,
Fax page 1 of Form 8850 to MAXIMUS at: 703-683-1051
to verify if applicant: 1) is a TH, and 2) has an Individual
Work Plan from an Employment Network.
3 ETA Form 9061 – (Rev.June 2012)
QUESTIONS 20 and 21
Unemployment Insurance (UI) Claims Records
UI Wage Records
_________________________________________________________________________________________________________________________________
Box 23.(a) Signature. The person who completes the form signs the signature block. Options: (a) Employer or Authorized Representative, (b) SWA staff,
(c) Participating Agency staff, or (d) Applicant (If applicant is a minor, the parent or guardian must sign).
Box 24. Date. Enter the month, day and year when the form was completed.
Persons are not required to respond to this collection of information unless it displays a currently valid OMB Control Number. Respondent’s obligation to reply to these
questions is required to obtain and retain benefits per law 104-188. Public reporting burden for this collection of information is estimated to average 20 minutes per
response including the time for reading instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing burden to the U.S.
Department of Labor, Employment and Training Administration, Division of National Programs, Tools, and Technical Assistance, 200 Constitution Ave., NW,
Room C-4510, Washington, D.C. 20210 (Paperwork Reduction Project Control No. 1205-0371).
………………………………………………………………………………………………………………………………………………………………………………......
(Cut along dotted line and keep in your files)
TO: THE JOB APPLICANT OR EMPLOYEE,
Privacy Act Statement: The Internal Revenue Code of 1986, Section 51, as amended and its enacting
legislation, P.L. 104-188, specify that the State Workforce Agencies are the "designated" agencies
responsible for administering the WOTC certification procedures of this program. The information you have
provided completing this form will be disclosed by your employer to the State Workforce Agency. Provision
of this information is voluntary. However, the information is required for your employer to receive the
federal tax credit. IF THE INFORMATION YOU PROVIDE IS ABOUT A MEMBER OF YOUR FAMILY,
YOU SHOULD PROVIDE HIM/HER A COPY OF THIS NOTICE.
4 ETA Form 9061 – (Rev.June 2012)
Attachment 3: https://www.dol.gov/sites/dolgov/files/ETA/advisories/TEGL/2012/TEGL_4_12_Att3.pdf
U.S. Department Labor OMB No. 1205-0371
Employment and Training Administration Expiration Date: June 30, 2015
Conditional Certification
Work Opportunity Tax Credit
EMPLOYERS!
This form must be accompanied by IRS Form 8850.
If you do not have IRS Form 8850, call 202-693-2786 for a copy or download it from www.irs.gov or www.doleta.gov/wotc
Be sure to complete Part II of this form and IRS 8850, sign and date both forms BEFORE sending them to the
State Workforce Agency (SWA) within 28 days after the new hire’s employment-start date.
1. INITIATING AGENCY CODE (For Agency Use Only) 2. CONTROL NO. (For Agency Use Only) “”
One)
CODE: ___________ ____ Participating Agency
____ SWA
3. FOR EX-FELON TARGET GROUP ONLY 4. DATE COMPLETED (MM/DD/YY)
a. Conviction Date: _________________ c. Correction’s (Ex-felon’s) ID No.___________
__________________________
b. Release Date: ___________________
5. STATE WORKFORCE AGENCY’s NAME/ADDRESS 6. SIGNATURE (Authorized Official) 7. TELEPHONE No.
PART I. APPLICANT’S INFORMATION AND CONDITIONAL CERTIFICATION (CC):
8. NAME OF APPLICANT (Last, First, Middle) 9. SOCIAL SECURITY No. 10. ENTER TARGET GROUP CODE
OTHER THAN “Veteran”:
________________________________
11. ADDRESS (Street, City, State, Zip Code) &Telephone No. 12. VETERAN TARGET GROUP CODES (“” One):
2Ba. Veteran receiving SNAP benefits
2Bb. Disabled Veteran
2Bc. Disabled Veteran unemployed for 6 months
2Bd. Veteran unemployed for 4 weeks but less than 6 months
2Be. Veteran unemployed for 6 months
13. APPLICANT SIGNATURE:
NOTE TO EMPLOYER:
In the event you hire this individual, you should request the certification necessary for you to
14. The above named individual may be eligible for certification
claim a Work Opportunity Tax Credit (WOTC). Simply complete and sign the Employer
under the Work Opportunity Tax Credit. If individual is not
Declaration below, submit to the SWA together with IRS Form 8850, not later than June 19,
employed before the date in the box below (Mo., Day, Yr.), this
eligibility determination is subject to review. 2012 for veterans that began employment for you on or after November 22, 2011 and
before May 22, 2012. For Veterans who began employment for you after May 22, 2012
and before Janaury1, 2013, submit to the SWA not later than 28 days after the
applicant started work. The WOTC Employer Certification will be sent to you, if all statutory
requirements have been met.
PART II. EMPLOYER DECLARATION: I, hereby, declare that the above named person is or will be employed by:
15. NAME OF FIRM AND ADDRESS: 16. POSITON/JOB TITLE: 17. EMPLOYMENT-START DATE: 18. STARTING WAGE:
$ ___________ per hr
ATTN SWA: Please send a WOTC Certification for this employee. The pre-certification is for the purpose of requesting Certification to obtain the WOTC under
Sec. 51 and 52 of the Internal Revenue Code. Employers are advised that such credit will cease immediately upon notification of any subsequent
invalidation/revocation.
NOTE: Falsification of data on this form is a FEDERAL CRIME in violation of 18 USC 1001. Falsification of work or concealment of information is
PUNISHABLE by a fine or imprisonment.
19. EMPLOYER’S NAME: 20. EMPLOYER’S SIGNATURE: 21. DATE: ((MM/DD/YY)
Page 1 of 3 ETA Form 9062 (Rev. June 2012)
CONDITIONAL CERTIFICATION (CC) ETA FORM 9062. When a SWA or participating agency (PA) determines that a job-ready
applicant is, tentatively, ELIGIBLE as a member of a target group under WOTC, it shall use this required form, without modification, to
show that an eligibility pre-determination was made for this person. Note. The CC serves as an official record of the pre-certification,
alerts prospective employers to the availability of the tax credit if this veteran is hired, and provides a means for employers to request
a WOTC certification for this person.
INSTRUCTIONS FOR COMPLETING THE “CONDITIONAL CERTIFICATION” FORM. (Boxes 1-8 and 15 are for participating
agency (PA) and SWA use only)
Box 1: Initiating Agency Code. If the CC was issued by a Participating Agency, enter its code. SWAs assign codes to
designate each PA and indicate the initiating source for the eligibility determination process. If the eligibility
determination was performed by the SWA, enter the SWA’s code, if available. Indicate with a check mark “” if initiating
agency is a PA or SWA.
Box 2: Control Number. Usually the PA determines the control number (CN). However, SWAs may, for internal control purposes,
develop their own CN system. It may be a case number or some other appropriate designation (e.g., alpha-numeric
designation), which permits easy filing, certification and retrieval of forms. Enter corresponding CN and indicate with a check
mark “” whether the source is a PA or a SWA.
Box 3: For Ex-Felon Target Group Only. For items a - c, enter the corresponding information. This information will help the SWA or
PA in verifying target group eligibility. Note: Box 4 does not apply to veterans hired under the VOW to Hire Heroes Act of
2011.
Box 4: Date Completed. Enter the month, day, year in which the eligibility determination was completed.
Box 5: SWA’s Name and Address. If known, enter or stamp the name and address, including zip code, of the SWA responsible for
Certification requests for the employer indicated in Box 16. Leave blank if SWA’s name and address is unknown.
Box 6: Signature. Enter signature of the authorized conditionally-certifying official.
Box 7: Telephone No. Enter corresponding SWA or PA area code, telephone number and extension, if available.
PART I. APPLICANT’S INFORMATION AND CONDITIONAL CERTIFICATION (CC):
Box 8: Name of Individual. Enter the individual’s/applicant’s full name (i.e., last name, first name and middle initial).
Box 19: Social Security Number. Enter the individual’s/applicant’s Social Security Number.
Box 10: Target Group Code. Enter the code or name of the pre-certified non-veteran group.
This box does not apply until Congress reauthorizes the non-veteran groups beyond December 31, 2011.
Box 11: Address/Telephone No. Enter the individual’s/applicant’s home address, including apartment number and zip code. After
address, enter individual’s telephone number, including area code.
Box 12: Target Group Code. The 1996 original target group designation for a Qualified Veteran is “B.” To facilitate the identification of
the different veteran categories created by the VOW to Hire Heroes Act of 2011 (P.L. 112-56,), ETA is using the same alpha-
numeric designations used to collect the number of certifications issued for the amended veteran categories in ETA Form 9058
– Report 1. To ensure a simple, uniform and consistent certification system which can be used by the SWAs nationwide each
new veteran category is preceded by “B” and followed by the alpha-numeric code used in ETA Form 9058. Enter a check
mark “” in front of the veteran group certified.
Box 13: Signature. Get applicant’s signature. If a minor, parent or guardian must sign here.
Box 14: CC Validity Period. (This box is to be completed by the SWA or PA). Enter the month/day/year when the CC expires.
This box does not apply to veterans pre-certified under the VOW to Hire Heroes Act of 2011.
Page 2 of 3
Page 1 of 3 ETA Form 9062 (Rev. June 2012)
Part II. EMPLOYER DECLARATION:
Box 15: Name of Firm. Enter full name of the employing firm (the firm where the employee will actually work).
Box 16: Position/Job Title. Enter the position or job title the employee will hold.
Box 17: Employment-Start Date. Enter the date the employee began or will begin work for the employing firm.
Box 18: Starting Wage. Enter the wage or salary which the employee will be paid. If not known, enter an estimated wage.
Box 19: Employer’s Name. Enter your name as the hiring employer.
Box 20: Employer’s Signature. Affix your electronic or ink signature here.
Box 21: Date. Enter month, day and year when you signed this form.
Persons are not required to respond to this collection of information unless it displays a currently valid OMB Control Number.
Respondents’ obligation to reply to these questions is required for obtaining the tax credit per P.L. 104-188. Public reporting burden
for this collection of information is estimated to average .33 minutes per response, including the time for reading instruction, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing the
burden to the U.S. Department of Labor, Employment and Training Administration, Division of National Programs, Tools, and
Technical Assistance, 200 Constitution Ave., NW, Room C-4510, Washington, D.C. 20210 (Paperwork Reduction Project 1205-
0371)
Privacy Act Statement: The Internal Revenue Code of 1986, Section 51, as amended and its enacting legislation, P.L.
104-188, specify that the State Workforce Agencies are the "designated" agencies responsible for administering the WOTC
certification procedures of this program. The information you have provided completing this form will be disclosed by your
employer to the State Workforce Agency. Provision of this information is voluntary. However the information is required
for your employer to receive the federal tax credit. IF THE INFORMATION YOU PROVIDE IS ABOUT A MEMBER OF
YOUR FAMILY, YOU SHOULD PROVIDE HIM/HER A COPY OF THIS NOTICE.
Page 13 of
Page of33
ETA Form 9062 (Rev. June 2012)
Attachment 4: https://www.dol.gov/sites/dolgov/files/ETA/advisories/TEGL/2012/TEGL_4_12_Att4.pdf
U.S. Department Labor OMB No. 1205-0371
Employment and Training Administration Expiration Date: June 30, 2015
Employer Certification
Work Opportunity Tax Credit
(OPTIONAL FORMAT)
1. NAME/ADDRESS OF CERTIFYING 2. CONTROL NO. (For 3. DATE COMPLETED:
Agency Use Only)
AGENCY AND TELEPHONE NO.
4. INITIATING AGENCY CODE (For Agency Use Only)
PART A. EMPLOYER
5. NAME/ADDRESS OF FIRM/TELEPHONE NO. 6. EMPLOYER TAX EIN #: 7. REPRESENTATIVE’S NAME, TITLE &
ADDRESS.
PART B. EMPLOYEE
8. SOCIAL SECURITY NO. 9. EMPLOYMENT START DATE (Mo/ Day/Yr.)
10. NAME AND ADDRESS OF EMPLOYEE: 12. VETERAN TARGET GROUP CODES: (“” those that apply)
2Ba. Veteran receiving SNAP benefits
2Bb. Disabled Veteran
2Bc. Disabled Veteran unemployed for 6 months
11. NON-VETERAN TARGET GROUP CODE AND 2Bd. Veteran unemployed for 4 weeks but less than 6 months
NAME: 2Be. Veteran unemployed for 6 months
________________________________________
PART C. CERTIFICATION
I, HEREBY, CERTIFY that the individual named in Part B meets the eligibility criteria of Sec. 51 or 52 of the Internal Revenue
Code.
13. NAME OF CERTIFYING OFFICER (Print or Type) 14. SIGNATURE. (Certifying Officer) 15. DATE ISSUED:
Comments to Employers:
* The VOW to Hire Heroes Act of 2011 (P.L. 112-56) extends and amends the current veteran group, creates two additional
categories of unemployed veterans in Section 51 of the Internal Revenue Code, and makes the WOTC available to
qualified tax-exempt organizations in Section 52. The VOW Act grants the WOTC to employers that hire certain qualified
veterans who begin employment on or after November 22, 2011 and before January 1, 2013. This Act did not extend the
non-veteran WOTC categories, which expired on December 31, 2011.
For additional information on filing certification requests to the State Workforce Agencies (SWA) and veterans’ eligibility
requirements visit WOTC’s national website at www.doleta.gov/wotc to obtain an e-copy of TEGL No. 30-11, a brochure on
“WOTC and Veterans” and a Fact Sheet that provides an overview of the provisions in the VOW Act. Employers are also
encouraged to visit IRS’s website at www.irs.gov to obtain e-copies of IRS’s Notice 2012 -13 and the January 2012 IRS Form
8850 and Instructions.
EMPLOYERS: Before you can claim the WOTC, your new hire(s) must work the required number of hours to meet the
Minimum Employment or Retention Period. Visit IRS’s website at: www.irs.gov for additional information on this and other
requirements.
Note. More information is available in the instructions for IRS Form 8850 & 5884, Work Opportunity Credit, for tax year 2012.
NOTE: Falsification of data to obtain this Certification is a FEDERAL CRIME in violation of 18 USC 1001. Falsification of work or concealment of information
is PUNISHABLE by a fine or imprisonment
Page of 1 of 2 ETA Form 9063 (Rev. June 2012)
INSTRUCTIONS FOR COMPLETING AND ISSUING THE CERTIFICATION FORM (CF) ETA 9063.
Documentary evidence of eligibility or collateral contacts is required to issue a WOTC Certification.
Information on the Certification substantiates the employer is entitled to claim a tax credit against the
first-year wages paid to the new hire.
Note: SWAs must inform each employer who receives a WOTC Certification of the required Minimum
Employment Period as stated in the "Comment Box" of the Certification. However, enforcement of this
requirement is, strictly, an IRS responsibility.
Boxes to be completed on the Certification:
Box 1: Name and Address. Identify the SWA and include the appropriate address and zip code.
Box 2. Control Number. Enter the control number developed by the SWA for its own use.
Box 3. Date Completed. Enter the month, day and year when the form was completed.
Box 4. Initiating Agency Code. Enter agency code developed by SWA for its own use.
Box 5. Name and Address of Firm. Enter employer's name and address including zip code.
Box 6. Employer Tax EIN Number. Enter employer’s taxpayer identification.
Box 7. Representative's Name, Title and Address. Enter the name, title and office location of the
individual authorized by the employer to act on the employer’s behalf.
Box 8. Social Security No. Enter the employee's social security number.
Box 9. Employment Start Date. Enter the month, day and year when the employee began to work for the
employing firm.
Box 10. Name and Address of Employee. Enter the employee's full name (i.e., last name, first and initial)
and address including zip code and telephone number, if available.
Box 11. Targeted Groups. Enter SWA Code and target group name for the certified group. This box
does not apply until Congress reauthorizes the non-veteran groups beyond December 31,
2011.
Box 12. Targeted Groups. Indicate, with a check mark ( “ “), which veteran group is being certified.
Box 13. Certifying Official. Key in/print full name and title of authorized certifying official.
Box 14. Signature. Enter authorized, certifying official's signature.
Box 15. Date. Enter month, day and year when the Certification is issued by the certifying official.
Persons are not required to respond to this collection of information unless it displays a currently valid OMB Control
Number. Respondent's obligation to reply to these requirements is mandatory under P.L. 104-188. Public reporting burden
for this collection of Information is estimated to average .33 minutes per response, including the time for reading
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the information. Send comments regarding the burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to the U.S. Department of Labor, Division of National Programs, Tools,
and Technical Assistance, Room C-4510, Washington, D.C. 20210 (Paperwork Reduction Project Control No. 1205-
0371).
============================================================================================
Privacy Act Statement: The Internal Revenue Code of 1986, Section 51, as amended and its enacting legislation, P.L.
104-188, specify that the State Workforce Agencies are the "designated" agencies responsible for administering the
WOTC certification procedures of this program. The information you have provided completing this form will be disclosed
by your employer to the State Workforce Agency. Provision of this information is voluntary. However the information is
required for your employer to receive the federal tax credit. IF THE INFORMATION YOU PROVIDE IS ABOUT A
MEMBER OF YOUR FAMILY, YOU SHOULD PROVIDE HIM/HER A COPY OF THIS NOTICE.
Page 2 of 2 ETA Form 9063 (Rev. June 2012)
Attachment 5: https://www.dol.gov/sites/dolgov/files/ETA/advisories/TEGL/2012/TEGL_4_12_Att5.pdf
Work Opportunity Tax Credit Program
U. S. Department of Labor OMB No. 1205-0371
Employment & Training Administration (For SWAs’ Internal Use Only) Expiration Date: June 30, 2015
1. NAME OF INDIVIDUAL 2. SOCIAL SECURITY NO.
Agency Declaration of Verification
Results Worksheet
3. EMPLOYER’S NAME, TELEPHONE NO., AND ADDRESS:
THE SECTION BELOW IS TO BE COMPLETED BY THE SWA CERTIFYING AGENCY ONLY.
4. CERTIFYING AGENCY: (Check one) 5. DATE CERTIFIED:
CC Issued By: ___ Participating Agency or ___ SWA
6. SOURCES USED TO DOCUMENT ELIGIBILITY:
7. AUDIT SAMPLE RESULTS (Complete ONLY if selected as part of RANDOM SAMPLE in quarterly audit)
a. I have reviewed/contacted the source(s) indicated in box 6 above and have confirmed that the certified individual is
ELIGIBLE.
b. I have reviewed/contacted the source(s) indicated in box 6 above and have confirmed that the certified individual is INELIGIBLE for
the following reason(s):
c. I have not been able to establish that the certified individual is INELIGIBLE because:
NOTE: Falsification of data on this form is a FEDERAL CRIME in violation of 18 USC 1001. Falsification of work or
concealment of information is PUNISHABLE by a FINE or IMPRISONMENT.
8. NAME AND TITLE OF REVIEWER (Type or Print): 9. SIGNATURE (Certifying Officer) 10. DATE:
Persons are not required to respond to this collection of information unless it displays a valid OMB Control Number. Respondent's
obligation to reply to these requirements is mandatory by P.L. 104-188. Public reporting burden for this collection of information is
estimated to average 1 hour per response, including the time for reading instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the information. Send comments regarding the burden estimate or any other
aspect of this collection of information including suggestions for reducing this burden to the US. Department of Labor, Division of National
Programs, Tools, and Technical Assistance, Room C-4510, Washington, D.C. 20210 (Paperwork Reduction Project 1205-0371).
Privacy Act Statement: The Internal Revenue Code of 1986, Section 51, as amended and its enacting legislation, P.L. 104-
188, specify that the State Workforce Agencies are the "designated" agencies responsible for administering the WOTC
certification procedures of this program. The information you have provided completing this form will be disclosed by your
employer to the State Workforce Agency. Provision of this information is voluntary. However the information is required for
your employer to receive the federal tax credit. IF THE INFORMATION YOU PROVIDE IS ABOUT A MEMBER OF YOUR
FAMILY, YOU SHOULD PROVIDE HIM/HER A COPY OF THIS NOTICE.
Page of 1 of 2 ETA Form 9065 (Rev. June 2012)
Previous versions usable
Instructions for Completing the Agency Declaration of Verification Results (ADVR) Worksheet, ETA FORM 9065.
Background: The Omnibus Budget Reconciliation Act of 1990, P. L. 101-508, § 11405(c), extended indefinitely the $5 million set-
aside (cited below) for testing whether individuals certified as members of WOTC targeted groups are eligible for certification
(including the use of statistical sampling techniques). As long as there is a WOTC appropriation, this requirement continues in
force. These provisions apply in full force to the certification process under the consolidated WOTC Program. Section 261(f)(2) of the Economic
Recovery Tax act of 1981 (P .L. 97-34), as amended, states that:
“(A) $5,000,000, shall be used to test whether individuals certified as members of targeted groups under
section 51of such Code [Internal Revenue] are eligible for such certification (including the use of
statistical sampling techniques), and (B) the remainder shall be distributed under performance standards
prescribed by the Secretary of Labor.”
Note. Verification activities require testing the validity of all Certifications issued by the SWAs, including the Conditional Certifications issued by
Participating Agencies (PAs) and other documentation, which results in Certifications. Quality reviews and audits are both parts of the
certification process. A General Accounting Office (GAO) report recommended that verification activities be done by "other than the person who
originally processed..." the Individual Characteristics [ETA Form 9061] or the Conditional Certification [ETA Form 9062] forms.
DEFINITIONS:
1. Quality Reviews - the reviews conducted at specific points in the eligibility determination/certification process of forms and
other documentation including the Certification itself to ensure that the required information is complete, consistent and accurately
recorded.
2. Audit - the post-issuance examination of a random sample of Certifications and supporting documentation to verify the validity of
the Certifications issued.
INSTRUCTIONS FOR COMPLETING THE AGENCY DECLARATION OF VERIFICATION RESULTS (ADVR) FORM.
Box 1. Name of Individual. Enter the full name (last, first and middle initial) of the certified target group member/employee.
Box 2. Social Security No. Enter the employee's social security number.
Box 3. Employer Name, Telephone No., & Address. Enter employer's name and address including zip code and telephone
number.
Box 4. Certifying Agency. Enter name of SWA issuing the Certification. Indicate with a check mark “” whether
the CC was issued by a Participating Agency or a SWA.
Box 5. Date Certified. Enter month, day and year when the Certification was issued.
Box 6. Documentary Sources. List and/or describe the documentary evidence or sources of collateral contacts that are attached to
the Certification request (IRS 8850) and/or Individual Characteristics Form.
Box7. Audit Sample Results. Indicate with a check mark “” if individual is "eligible," "ineligible” or “eligibility cannot be determined”
and follow the instructions below.
a. If review of documentation reveals that the certified individual is eligible, enter a check mark“.”
b. If review of documentation reveals that the certified individual is ineligible, explain why, and for Conditional
Certifications (CCs) prepare and send the following notices:
Notification of Invalidation (NOI) - to the applicant, the SWA, PA staff; and employer/consultant. The NOI notifies
the employer/consultant to whom applicant was referred that the CC (ETA form 9062) is invalid because of missing or
incorrect information/items and that without such information a Certification cannot be issued.
Notice of Revocation (NOR) - prepare and send to employer/consultant an NOR explaining the reasons for
revocation and send a copy to the Regional Office and IRS in your state since employer eligibility for the tax credit
does not cease until the date that the employer is, officially, notified in writing that the Certification (ETA Form
9063) has been invalidated; thereby, revoked.
c. If review of documentation reveals that the SWA has not been able to establish eligibility explain the reason.
Box 8. Name and Title of Reviewer. Enter full name and title of authorized staff conducting audit review.
Box 9. Signature. Enter signature of authorized reviewer conducting audit.
Box 10. Date. Enter month, day and year when audit was conducted.
Page 2 of 2 ETA Form 9065 (Rev. June 2012)
Attachment 6: https://www.dol.gov/sites/dolgov/files/ETA/advisories/TEGL/2012/TEGL_4_12_Att6.pdf
Form 8850
(Rev. January 2012)
Pre-Screening Notice and Certification Request for
the Work Opportunity Credit OMB No. 1545-1500
Department of the Treasury
Internal Revenue Service a See separate instructions.
Job applicant: Fill in the lines below and check any boxes that apply. Complete only this side.
Your name Social security number a
Street address where you live
City or town, state, and ZIP code
County Telephone number
If you are under age 40, enter your date of birth (month, day, year)
1 Check here if you received a conditional certification from the state workforce agency (SWA) or a participating local agency
for the work opportunity credit.
2 Check here if any of the following statements apply to you.
• I am a member of a family that has received assistance from Temporary Assistance for Needy Families (TANF) for any 9
months during the past 18 months.
• I am a veteran and a member of a family that received Supplemental Nutrition Assistance Program (SNAP) benefits (food
stamps) for at least a 3-month period during the past 15 months.
• I was referred here by a rehabilitation agency approved by the state, an employment network under the Ticket to Work
program, or the Department of Veterans Affairs.
• I am at least age 18 but not age 40 or older and I am a member of a family that:
a Received SNAP benefits (food stamps) for the past 6 months, or
b Received SNAP benefits (food stamps) for at least 3 of the past 5 months, but is no longer eligible to receive them.
• During the past year, I was convicted of a felony or released from prison for a felony.
• I received supplemental security income (SSI) benefits for any month ending during the past 60 days.
• I am a veteran and I was unemployed for a period or periods totaling at least 4 weeks but less than 6 months during the
past year.
3 Check here if you are a veteran and you were unemployed for a period or periods totaling at least 6 months during the past
year.
4 Check here if you are a veteran entitled to compensation for a service-connected disability and you were discharged or
released from active duty in the U.S. Armed Forces during the past year.
5 Check here if you are a veteran entitled to compensation for a service-connected disability and you were unemployed for a
period or periods totaling at least 6 months during the past year.
6 Check here if you are a member of a family that:
• Received TANF payments for at least the past 18 months, or
• Received TANF payments for any 18 months beginning after August 5, 1997, and the earliest 18-month period beginning
after August 5, 1997, ended during the past 2 years, or
• Stopped being eligible for TANF payments during the past 2 years because federal or state law limited the maximum time
those payments could be made.
Signature—All Applicants Must Sign
Under penalties of perjury, I declare that I gave the above information to the employer on or before the day I was offered a job, and it is, to the best of my knowledge, true,
correct, and complete.
Job applicant’s signature a Date
For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 22851L Form 8850 (Rev. 1-2012)
Form 8850 (Rev. 1-2012) Page 2
For Employer’s Use Only
Employer’s name Telephone no. EIN a
Street address
City or town, state, and ZIP code
Person to contact, if different from above Telephone no.
Street address
City or town, state, and ZIP code
If, based on the individual’s age and home address, he or she is a member of group 4 or 6 (as described under Members of
Targeted Groups in the separate instructions), enter that group number (4 or 6) . . . . . . . . . . . . . . a
Date applicant:
Gave Was Was Started
information offered job hired job
Under penalties of perjury, I declare that the applicant provided the information on this form on or before the day a job was offered to the applicant and that the
information I have furnished is, to the best of my knowledge, true, correct, and complete. Based on the information the job applicant furnished on page 1, I
believe the individual is a member of a targeted group. I hereby request a certification that the individual is a member of a targeted group.
Employer’s signature a Title Date
Privacy Act and criminal litigation, to the Department of The time needed to complete and file
Labor for oversight of the certifications this form will vary depending on
Paperwork Reduction performed by the SWA, and to cities, individual circumstances. The estimated
Act Notice states, and the District of Columbia for average time is:
use in administering their tax laws. We
Recordkeeping . . 6 hr., 27 min.
Section references are to the Internal may also disclose this information to
Revenue Code. other countries under a tax treaty, to Learning about the law
federal and state agencies to enforce or the form . . . . . . . 30 min.
Section 51(d)(13) permits a prospective federal nontax criminal laws, or to
employer to request the applicant to Preparing and sending this form
federal law enforcement and intelligence
complete this form and give it to the to the SWA . . . . . . . 37 min.
agencies to combat terrorism.
prospective employer. The information If you have comments concerning the
will be used by the employer to You are not required to provide the
accuracy of these time estimates or
complete the employer’s federal tax information requested on a form that is
suggestions for making this form
return. Completion of this form is subject to the Paperwork Reduction Act
simpler, we would be happy to hear from
voluntary and may assist members of unless the form displays a valid OMB
you. You can write to the Internal
targeted groups in securing employment. control number. Books or records
Revenue Service, Tax Products
Routine uses of this form include giving relating to a form or its instructions must
Coordinating Committee,
it to the state workforce agency (SWA), be retained as long as their contents
SE:W:CAR:MP:T:M:S, 1111 Constitution
which will contact appropriate sources may become material in the
Ave. NW, IR-6526, Washington, DC
to confirm that the applicant is a administration of any Internal Revenue
20224.
member of a targeted group. This form law. Generally, tax returns and return
may also be given to the Internal information are confidential, as required Do not send this form to this address.
Revenue Service for administration of by section 6103. Instead, see When and Where To File in
the Internal Revenue laws, to the the separate instructions.
Department of Justice for civil and
Form 8850 (Rev. 1-2012)
Department of the Treasury
Instructions for Form 8850 Internal Revenue Service
(Rev. January 2012)
Pre-Screening Notice and Certification Request for the Work Opportunity Credit
General Instructions Instructions for Employer
Section references are to the Internal Revenue Code unless
otherwise noted.
When and Where To File
What’s New Do not file Form 8850 with the Internal Revenue Service.
Instead, file it with your SWA no later than the 28th day after
• For certain veterans who begin work after November 21, the job applicant begins work for you (by June 19, 2012, for
2011, and before 2013, the qualified veteran targeted group all qualified veterans who begin work after November 21,
has been expanded to cover veterans who were 2011, and before May 22, 2012).
unemployed for at least 4 weeks during the 1-year period
ending on the hiring date. Although facsimile filing of Form 8850 is permitted, not all
• The Hurricane Katrina employee targeted group expired states are equipped to accept a faxed copy of Form 8850.
for individuals hired after August 27, 2009. Contact your state WOTC coordinator as discussed below
• The unemployed veteran and disconnected youth and see Notice 2012-13 for details. Notice 2012-13 is
targeted groups expired for individuals hired after 2010. available at www.irs.gov/pub/irs-drop/n-12-13.pdf.
• The empowerment zone designations were extended until Although electronic filing of Form 8850 is permitted, at
the end of 2011. the time these instructions were published, only the
• The renewal community designations expired at the end following states are equipped to receive Form 8850
of 2009. electronically: Alabama, Arizona, Arkansas, Colorado,
• Some states may be equipped to accept a faxed copy of Florida, Illinois, Kansas, Kentucky, Minnesota, New Jersey,
Form 8850 and additional states are equipped to receive Ohio, Pennsylvania, and South Carolina. See
Form 8850 electronically. Announcement 2002-44 and Notice 2012-13 for details. You
can find Announcement 2002-44 on page 809 of Internal
• The IRS has created a page on IRS.gov for information Revenue Bulletin 2002-17 at
about Form 8850 and its instructions at www.irs.gov/ www.irs.gov/pub/irs-irbs/irb02-17.pdf.
form8850. Information about any future developments
affecting Form 8850 (such as legislation enacted after we To get the name, address, phone and fax numbers, and
release it) will be posted on that page. email address of the WOTC coordinator for your state, visit
the Department of Labor Employment and Training
Administration (ETA) website at
Purpose of Form www.doleta.gov/business/Incentives/opptax.
Employers use Form 8850 to pre-screen and to make a
written request to their state workforce agency (SWA) to Never attach Form 8850 to a tax return or otherwise
certify an individual as a member of a targeted group for
purposes of qualifying for the work opportunity credit.
! send it to the IRS, regardless of the employee’s
CAUTION targeted group. Form 8850 should be filed with the
SWA.
Submitting Form 8850 to the SWA is but one step in the
process of qualifying for the work opportunity credit. The
state work opportunity tax credit (WOTC) coordinator for the Additional Requirements for
SWA must certify the job applicant is a member of a
targeted group. After starting work, the employee must meet Certification
the minimum number-of-hours-worked requirement for the In addition to filing Form 8850, you must complete and send
work opportunity credit. Generally, an employer elects to to your state WOTC coordinator either:
take the credit by filing Form 5884, Work Opportunity Credit. • ETA Form 9062, Conditional Certification Form, if the job
However, a tax-exempt organization that hires a qualified applicant received this form from a participating agency
veteran should report the work opportunity credit on Form (e.g., the Jobs Corps), or
5884-C, Work Opportunity Credit for Qualified Tax-Exempt • ETA Form 9061, Individual Characteristics Form, if the job
Organizations Hiring Qualified Veterans. applicant did not receive a conditional certification.
You can get ETA Form 9061 from your local public
Who Should Complete and employment service office or you can download it from the
ETA website at
Sign the Form www.doleta.gov/business/Incentives/opptax.
The job applicant gives information to the employer on or
before the day a job offer is made. This information is
entered on Form 8850. Based on the applicant’s Recordkeeping
information, the employer determines whether or not he or Keep copies of Forms 8850, any transmittal letters that you
she believes the applicant is a member of a targeted group submit to your state WOTC coordinator, and certification
(as defined under Members of Targeted Groups). If the letters you receive from your WOTC coordinator as long as
employer believes the applicant is a member of a targeted they may be needed for the administration of the provisions
group, the employer completes the rest of the form no later relating to the work opportunity credit. Records that support
than the day the job offer is made. Both the job applicant the credit usually must be kept for 3 years from the date any
and the employer must sign Form 8850 no later than the income tax return claiming the credit is due or filed,
date for submitting the form to the SWA. whichever is later.
Feb 09, 2012 Cat. No. 24833J
Members of Targeted Groups a. Has received SNAP benefits for the 6-month period
ending on the hiring date, or
A job applicant may be certified as a member of a targeted b. Is no longer eligible for such assistance under section
group if he or she is described in one of the following 6(o) of the Food Stamp Act of 1977, but the family received
groups. SNAP benefits for at least 3 months of the 5-month period
1. Qualified IV-A recipient. An individual who is a ending on the hiring date.
member of a family receiving assistance under a state plan 8. SSI recipient. An individual who is receiving
approved under part A of title IV of the Social Security Act supplemental security income benefits under title XVI of the
relating to Temporary Assistance for Needy Families Social Security Act (including benefits of the type described
(TANF). The assistance must be received for any 9 months in section 1616 of the Social Security Act or section 212 of
during the 18-month period ending on the hiring date. Public Law 93-66) for any month ending during the 60-day
2. Qualified veteran. A veteran who is any of the period ending on the hiring date.
following. 9. Long-term family assistance recipient. An
• A member of a family receiving assistance under the individual who is a member of a family that:
Supplemental Nutrition Assistance Program (SNAP) (food • Has received TANF payments for at least 18
stamps) for at least a 3-month period during the 15-month consecutive months ending on the hiring date, or
period ending on the hiring date. • Receives TANF payments for any 18 months (whether
• Unemployed for a period or periods totaling at least 4 or not consecutive) beginning after August 5, 1997, and the
weeks (whether or not consecutive) but less than 6 months earliest 18-month period beginning after August 5, 1997,
in the 1-year period ending on the hiring date. ended during the past 2 years, or
• Unemployed for a period or periods totaling at least 6 • Stopped being eligible for TANF payments because
months (whether or not consecutive) in the 1-year period federal or state law limits the maximum period such
ending on the hiring date. assistance is payable and the individual is hired not more
• Entitled to compensation for a service-connected than 2 years after such eligibility ended.
disability and is hired not more than 1 year after being
discharged or released from active duty in the U.S. Armed
Forces. Member of a Family
• Entitled to compensation for a service-connected With respect to the qualified IV-A recipient, qualified veteran,
disability and was unemployed for a period or periods recipient of SNAP benefits (food stamps), and long-term
totaling at least 6 months (whether or not consecutive) in the family assistance recipient, an individual whose family
1-year period ending on the hiring date. receives assistance for the requisite period meets the family
assistance requirement of the applicable group if the
Note. Requesting the information in box 4 or box 5 of Form individual is included on the grant (and thus receives
8850 is an exception to the Americans with Disabilities Act’s assistance) for some portion of the specified period.
prohibition on pre-offer disability-related inquiries. The
purpose of this request is to support the hiring of certain Empowerment Zones
disabled veterans, which will entitle the employer to a larger
work opportunity credit than the hiring of other targeted The following paragraphs describe current designations of
group members. empowerment zones. The designations will generally remain
To be considered a veteran, the applicant must: in effect until the end of 2011.
• Have served on active duty (not including training) in Urban areas. Parts of the following urban areas are
the Armed Forces of the United States for more than 180 empowerment zones. You can find out if your business or
days or have been discharged or released from active duty an employee’s residence is located within an urban
for a service-connected disability, and empowerment zone by using the EZ/RC Address Locator at
• Not have a period of active duty (not including training) www.hud.gov/crlocator or by calling 1-800-998-9999.
of more than 90 days that ended during the 60-day period • Pulaski County, AR
ending on the hiring date. • Tucson, AZ
3. Qualified ex-felon. An ex-felon who has been • Fresno, CA
convicted of a felony under any federal or state law, and is • Los Angeles, CA (city and county)
hired not more than 1 year after the conviction or release • Santa Ana, CA
from prison for that felony. • New Haven, CT
4. Designated community resident. An individual who • Jacksonville, FL
is at least age 18 but not yet age 40 on the hiring date and • Miami/Dade County, FL
lives within an empowerment zone or rural renewal county • Chicago, IL
(defined later). • Gary/Hammond/East Chicago, IN
5. Vocational rehabilitation referral. An individual who • Boston, MA
has a physical or mental disability resulting in a substantial • Baltimore, MD
handicap to employment and who was referred to the • Detroit, MI
employer upon completion of (or while receiving) • Minneapolis, MN
rehabilitation services by a rehabilitation agency approved • St. Louis, MO/East St. Louis, IL
by the state, an employment network under the Ticket to • Cumberland County, NJ
Work program, or the Department of Veterans Affairs. • New York, NY
6. Summer youth employee. An individual who: • Syracuse, NY
• Performs services for the employer between May 1 and • Yonkers, NY
September 15,
• Cincinnati, OH
• Cleveland, OH
• Is at least age 16 but not yet age 18 on the hiring date • Columbus, OH
(or if later, on May 1), • Oklahoma City, OK
• Has never worked for the employer before, and • Philadelphia, PA/Camden, NJ
• Lives within an empowerment zone. • Columbia/Sumter, SC
7. Recipient of SNAP benefits (food stamps). An • Knoxville, TN
individual who: • El Paso, TX
• Is at least age 18 but not yet age 40 on the hiring date, • San Antonio, TX
and • Norfolk/Portsmouth, VA
• Is a member of a family that: • Huntington, WV/Ironton, OH
-2-
Washington, DC. Under section 1400, parts of Maine. The counties of Aroostook and Piscataquis.
Washington, DC, are treated as an empowerment zone. Michigan. The counties of Gogebic, Marquette, and
This treatment will generally remain in effect until the end of Ontonagon.
2011. For details, use the EZ/RC Address Locator at www. Minnesota. The counties of Big Stone, Chippewa,
hud.gov/crlocator or see Notice 98-57 on page 9 of Internal Cottonwood, Faribault, Jackson, Kittson, Koochiching, Lac
Revenue Bulletin 1998-47 at www.irs.gov/pub/irs-irbs/ Qui Parle, Lincoln, Marshall, Martin, Murray, Norman,
irb98-47.pdf. Pipestone, Red Lake, Redwood, Renville, Stevens,
Rural areas. Parts of the following rural areas are Traverse, Wilkin, and Yellow Medicine.
empowerment zones. You can find out if your business or Mississippi. The counties of Adams, Coahoma,
an employee’s residence is located within a rural Humphreys, Montgomery, Quitman, Sharkey, Tallahatchie,
empowerment zone by using the EZ/RC Address Locator at and Washington.
www.hud.gov/crlocator or by calling 1-800-998-9999.
• Desert Communities, CA (part of Riverside County) Missouri. The counties of Atchison, Carroll, Chariton,
• Southwest Georgia United, GA (part of Crisp County and Clark, Holt, Knox, Mississippi, New Madrid, Pemiscot, and
Worth.
all of Dooly County)
• Southernmost Illinois Delta, IL (parts of Alexander and Montana. The counties of Carter, Daniels, Dawson, Deer
Johnson Counties and all of Pulaski County) Lodge, Fallon, Garfield, Hill, Liberty, McCone, Petroleum,
• Kentucky Highlands, KY (part of Wayne County and all of Phillips, Powder River, Prairie, Richland, Roosevelt,
Clinton and Jackson Counties) Rosebud, Sheridan, Valley, and Wibaux.
• Aroostook County, ME (part of Aroostook County) Nebraska. The counties of Antelope, Banner, Boone, Box
• Mid-Delta, MS (parts of Bolivar, Holmes, Humphreys, Butte, Boyd, Burt, Cedar, Chase, Deuel, Dundy, Fillmore,
Leflore, Sunflower, and Washington Counties) Franklin, Garden, Garfield, Greeley, Hayes, Hitchcock, Holt,
• Griggs-Steele, ND (part of Griggs County and all of Steele Jefferson, Johnson, Logan, Nance, Nemaha, Nuckolls,
County) Pawnee, Perkins, Red Willow, Richardson, Rock, Sheridan,
• Oglala Sioux Tribe, SD (parts of Jackson and Bennett Sherman, Thayer, Thomas, Valley, Webster, and Wheeler.
Counties and all of Shannon County) Nevada. The counties of Esmeralda, Lander, and Mineral.
• Middle Rio Grande FUTURO Communities, TX (parts of New Hampshire. Coos County.
Dimmit, Maverick, Uvalde, and Zavala Counties)
• Rio Grande Valley, TX (parts of Cameron, Hidalgo, Starr, New Mexico. The counties of Harding and Quay.
and Willacy Counties) New York. The counties of Clinton and Montgomery.
North Dakota. The counties of Adams, Barnes, Benson,
Rural Renewal Counties Billings, Bottineau, Burke, Cavalier, Dickey, Divide, Dunn,
A rural renewal county is a county in a rural area that lost Eddy, Emmons, Foster, Golden Valley, Grant, Griggs,
population during the 5-year periods 1990 through 1994 and Hettinger, Kidder, LaMoure, Logan, McHenry, McIntosh,
1995 through 1999. Rural renewal counties are listed below. McKenzie, McLean, Mercer, Mountrail, Nelson, Oliver,
Pembina, Pierce, Ramsey, Ransom, Renville, Sargent,
Alabama. The counties of Butler, Dallas, Macon, Perry, Sheridan, Slope, Stark, Steele, Stutsman, Towner, Traill,
Sumter, and Wilcox. Walsh, Wells, and Williams.
Alaska. The census areas of Aleutians West, Ohio. The counties of Crawford, Monroe, Paulding,
Wrangell-Petersburg, and Yukon-Koyukuk. Seneca, and Van Wert.
Arkansas. The counties of Arkansas, Chicot, Clay, Desha, Oklahoma. The counties of Alfalfa, Beaver, Cimarron,
Jackson, Lafayette, Lee, Little River, Monroe, Nevada, Custer, Dewey, Ellis, Grant, Greer, Harmon, Harper, Kiowa,
Ouachita, Phillips, Union, and Woodruff. Major, Roger Mills, Seminole, Tillman, and Woodward.
Colorado. The counties of Cheyenne, Kiowa, and San Pennsylvania. The counties of Venango and Warren.
Juan.
South Carolina. Marlboro County.
Georgia. The counties of Randolph and Stewart.
South Dakota. The counties of Aurora, Campbell, Clark,
Illinois. The counties of Alexander, Edwards, Franklin, Day, Deuel, Douglas, Faulk, Grant, Gregory, Haakon, Hand,
Gallatin, Greene, Hancock, Hardin, Jasper, Knox, Harding, Hutchinson, Jones, Kingsbury, Marshall,
McDonough, Montgomery, Pulaski, Randolph, Richland, McPherson, Miner, Perkins, Potter, Sanborn, Spink, Tripp,
Scott, Warren, Wayne, and White. and Walworth.
Indiana. Perry County. Texas. The counties of Andrews, Bailey, Baylor, Borden,
Iowa. The counties of Adair, Adams, Appanoose, Audubon, Briscoe, Brooks, Castro, Cochran, Coleman, Collingsworth,
Butler, Calhoun, Cass, Cherokee, Clay, Clayton, Emmet, Cottle, Crane, Culberson, Deaf Smith, Dimmit, Eastland,
Floyd, Franklin, Fremont, Hancock, Humboldt, Ida, Keokuk, Fisher, Floyd, Foard, Gray, Hall, Hardeman, Haskell,
Kossuth, Montgomery, Osceola, Palo Alto, Pocahontas, Hemphill, Hockley, Hutchinson, Kenedy, Kent, Knox, Lamb,
Poweshiek, Sac, Taylor, Union, Wayne, Winnebago, and Martin, McCulloch, Morris, Nolan, Oldham, Reagan,
Worth. Reeves, Refugio, Roberts, Scurry, Stonewall, Terrell, Terry,
Kansas. The counties of Atchison, Barber, Barton, Brown, Upton, Ward, Wheeler, Wilbarger, Winkler, Yoakum, and
Clay, Cloud, Comanche, Decatur, Edwards, Elk, Ellsworth, Zavala.
Gove, Graham, Greeley, Greenwood, Harper, Hodgeman, Virginia. The counties of Buchanan, Dickenson, Highland,
Jewell, Kiowa, Labette, Lane, Lincoln, Marshall, Mitchell, and Lee and the independent cities of Clifton Forge,
Montgomery, Ness, Osborne, Phillips, Rawlins, Republic, Covington, Norton, and Staunton.
Rooks, Rush, Russell, Scott, Sheridan, Sherman, Smith, West Virginia. The counties of Calhoun, Gilmer, Logan,
Stafford, Trego, Wallace, Washington, Wichita, and McDowell, Mercer, Mingo, Summers, Tucker, Webster,
Woodson. Wetzel, and Wyoming.
Kentucky. The counties of Bell, Caldwell, Floyd, Harlan, Wyoming. The counties of Carbon and Niobrara.
Hickman, Leslie, Letcher, Pike, and Union.
Louisiana. The parishes of Bienville, Claiborne, Franklin,
Jackson, Morehouse, St. Mary, Tensas, Vernon, and
Webster.
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