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New approval expiration for Work Opportunity Tax Credit forms
Summary ETA notified states that four Work Opportunity Tax Credit reporting and certification forms had been approved without changes through August 31, 2018. The four forms are attached. ETA now labels the letter Canceled, so the attached forms are historical.
Document
Federal guidance
Agency
U.S. Department of Labor, Employment and Training Administration (ETA)
Document number
TEGL No. 9-15
Date issued
November 17, 2015
Status
Withdrawn
ETA lists this letter Canceled as of 2026-10-24; its PDF prints Expiration Date: Continuing and Rescissions: None. The form approval described in this letter ran through August 31, 2018; no cancellation instrument is identified.
Status last verified October 24, 2026
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About this page: The full text below is the official document from U.S. Department of Labor, Employment and Training Administration (ETA). Ezel adds the plain-English summary and tracks the document's status. The official source linked on this page is authoritative for any reliance.
CLASSIFICATION
EMPLOYMENT AND TRAINING ADMINISTRATION WOTC
ADVISORY SYSTEM CORRESPONDENCE SYMBOL
U.S. DEPARTMENT OF LABOR OWI
Washington, D.C. 20210 DATE
November 17, 2015
ADVISORY: TRAINING AND EMPLOYMENT GUIDANCE LETTER NO. 9-15
TO: ALL STATE WORKFORCE ADMINISTRATORS
FROM: BYRON ZUIDEMA /s/ for PORTIA WU
Assistant Secretary
SUBJECT: New Expiration Date for Work Opportunity Tax Credit Program Forms
Under the Paperwork Reduction Act
l. Purpose. To inform State Workforce Agencies (SWAs) of Office of
Management and Budget (OMB) approval of the extension, without any changes,
of the Work Opportunity Tax Credit (WOTC) reporting, administrative, and
processing forms under the Paperwork Reduction Act of 1995 (PRA).
2. References.
• Training and Employment Guidance Letter (TEGL) No. 28-14,
Reauthorization of the Work Opportunity Tax Credit (WOTC) Program for
2014 and Authorization Lapse for 2015 (April 17, 2015)
• TEGL No. 4-12, Revised Forms for the WOTC Program for Implementation
of the Veterans Opportunity to Work to Hire Heroes Act of 2011 (VOW Act)
Provisions and Other Program Changes (July 31, 2012)
• ETA Handbook No. 408, November 2002, Third Edition (the Handbook)
• August 2009 Addendum to the Handbook
• Paperwork Reduction Act of 1995
3. Background. Given that the legislative authority for all WOTC target groups
expired December 31, 2014, ETA issued TEGL No. 28-14 on April 17, 2015,
which provided procedural guidance for SWAs to process WOTC certification
requests submitted before December 31, 2014, and to continue tracking and
collecting any certification requests made after December 31, 2014.
The SWAs, participating employers and their representatives, and participating
agencies continue to use the following WOTC processing, administrative, and
reporting forms:
• ETA Form 9058 - Report 1, “Certification Workload and Characteristics of
Certified Individuals, Work Opportunity Tax Credit,”
• ETA Form 9061, “Individual Characteristics Form, Work Opportunity Tax
Credit,”
RESCISSIONS EXPIRATION DATE
None Continuing
-2-
• ETA Form 9062, “Conditional Certification, Work Opportunity Tax Credit,”
and
• ETA Form 9063, “Employer Certification, Work Opportunity Tax Credit.”
These WOTC forms, which had previously been approved by OMB through June
30, 2015, are now approved to be used for an additional three-year period through
August 31, 2018.
4. Paperwork Reduction Act of 1995, Notice of Action and Reporting
Authority. ETA Forms 9058, 9061, 9062, and 9063, were approved by OMB,
without any changes, under the Paperwork Reduction Act (PRA) of 1995, under
OMB Control No. 1205-0371. The approval for these four forms is effective
through August 31, 2018.
According to the PRA, no persons are required to respond to a collection of
information unless such collection displays a valid OMB control number (1205-
0371). The U.S. Department of Labor 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 provision 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).
5. Transition Relief Period for SWAs and Employers. From now until 90 days
after the issuance of this TEGL, employers and their representatives can use
either the newly approved ETA Forms 9061 or 9062 (with the August 31, 2018,
expiration date) or the expired forms (with the June, July, or August 2015
expiration date) to request certifications for their new employees. After the 90
day transition period, SWAs should not accept the expired forms. ETA is
granting a transition period that allows employers to continue to file with the
SWAs the expired ETA Form 9061 or 9062 with the June 30, 2015, date.
6. IRS Form 8850. In the past IRS has indicated that expired versions of Form
8850 can be used to request certifications for new hires of the target groups listed
on that form only. In March 2015, the IRS released an unchanged Form 8850
with revised instructions for that form. This form and its instructions are
available at www.irs.gov/form8850. Employers and their representatives are
encouraged to visit the IRS website at www.irs.gov for any additional
information or updates.
7. Action Required. ETA requests that SWAs use the WOTC forms available at
http://www.doleta.gov/business/incentives/opptax/forms.cfm, and share them
with related program staff, employers and their representatives, participating
agencies, and other interested partners. If employers submit forms with a 2015
date, SWAs should accept those forms during the transition period described
-3-
above, as there have been no changes to the forms. ETA requests that employers
transition to the use of the new forms with the 2018 expiration date. SWAs
should accept any version of the IRS Form 8850, even those with an expiration
date before March 2015, if the information for the relevant target group is
included.
8. Inquiries. Direct all questions to the appropriate Regional WOTC Coordinator,
listed at
http://www.doleta.gov/business/incentives/opptax/Regional_Contacts.cfm.
9. Attachments.
• ETA Form 9058 - Report 1, “Certification Workload and Characteristics of
Certified Individuals, Work Opportunity Tax Credit”
• ETA Form 9061, “Individual Characteristics Form, Work Opportunity Tax
Credit”
• ETA Form 9062, “Conditional Certification, Work Opportunity Tax Credit”
• ETA Form 9063, “Employer Certification, Work Opportunity Tax Credit”
Attachment 1
Official attachment: https://www.dol.gov/sites/dolgov/files/ETA/advisories/TEGL/2015/TEGL_09-15_Attachment_1.pdf
Certification Workload and Characteristics of Certified U.S. Department of Labor
Individuals Employment and Training Administration
Work Opportunity Tax Credit - Report No. 1
State: Quarter Ending: 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 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 this
Date: August 31, 2018
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. K) By Starting (a) No.
I) By WOTC Target Resulting in Certified J) By Occupation Certified J) By Occupation (Cont.) Certified Hourly Wage Certified
Group Certifications Individuals Individuals Individuals 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
2Bd. V Unemployed for 4 3. Computer & Mathematical – 15 4. $9.00 -$9.99
weeks
2Be. V Unemployed for 6 4. Architecture & Engineering – 17 16. Sales & Related Occupations – 41 5. $10.00 – Higher
months
3. Ex-Felon 5. Life, Physical & Social Sciences – 19 17. Office/Administrative Support – 43 6. TOTAL (For Qtr.)
4. Summer Youth 6. Community & Social Services – 21 18. Farming, Fishing & Forestry – 45
5. Designated
Community Resident 7. Legal Occupations – 23 19. Construction & Extraction – 47
6a. Voc. Rehab Referral 8. Education, Training, & Library – 25 20. Installation/Maintenance/Repair- 49
9. Arts, Design, Entertainment, Sports/Media
6b. Ticket Holder Occupations – 27 21. Production Occupations – 51
22. Transportation & Material Moving
7. SNAP Recipient 10. Healthcare Practitioner & Technical – 29 Production Occupations – 53
8. SSI Recipient 11. Healthcare Support Occupations – 31 23. Military Specific Occupations – 55
9. Long-term TANF
10. TOTAL (For Qtr.)
11. 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. August 2015)
Instructions for Preparing ETA Form 9058, Report 1 –“Certification Workload and
Characteristics of Certified Individuals,” Work Opportunity Tax Credit Report
Introductions. 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 collect data on the expanded Veteran groups introduced by the VOW to Hire Heroes Act of
2011 (P.L. 112-56).
Form Updates. On January 2, 2013, President Obama signed into law the American Taxpayer
Relief Act of 2012 extending retroactively to December 31, 2011, the Empowerment Zones
(EZs) and the expired non-veteran target groups, and authorizing the continuation of the VOW to
Hire Heroes Act of 2011 expanded Veteran groups and provisions all through December 31,
2013. The statutory definition for the Summer Youth group, and the Designated Community
Resident (DCR) group, requires that the Youth and the DCR reside in an EZ as part of the
eligibility criteria. Box 4 was unshaded, named “Summer Youth” and placed below Box 3. Ex-
felon to collect quarterly data on SWAs’ determinations. Boxes 5-11 were renumbered as
follows: Box 5. Designated Community Resident, Box. 6a. Voc. Rehab Referral, Box 6b. Ticket
Holder, Box 7. SNAP Recipient, Box 8. SSI Recipient, Box 9. Long-Term TANF, Box 10. TOTAL
(For QTR.) and Box 11. 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”
Background. The purpose of ETA Form 9058 (Updated April 2013) 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 evaluated accurately 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).
Page 2 of 5 ETA Form 9058 (Rev. August 2015)
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.
(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 SW A, 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 SW A, but which the SW A could neither approve nor deny due to such things as, but not
limited to, the need for additional eligibility documentation for which the SW A 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.
Page 3 of 5 ETA Form 9058 (Rev. August 2015)
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.
Section I. Line #4. Enter the total number of WOTC certifications issued by the SWA during the current report
period for the Summer Youth group
Section I, Line #5. 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 #6a. Enter the total number of WOTC certifications issued by the SWA during the current report
period, for Vocational Rehabilitation Referrals.
Section I, Line #6b. 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 #7. 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 #8. Enter the total number of WOTC certifications issued by the SWA during the current report
period, for SSI recipients.
Section I, Line #9. Enter the total number of WOTC certifications issued by the SWA during the current report
period, for “Long-term TANF” Recipients.
Section I. Line #10. Enter the sums of columns (a) and (b) and also the total of Column I under Column K (By
Starting Salary for Boxes 10 and 11. Note. The total (For Qtr.) of Part II, Section I, Line #12, columns (a) & (b)
should equal the total entered in Part I. Item E. Requests Certified.
Section I, Line #11. Enter the cumulative federal program Year-to-Date (YTD) totals of columns (a) and (b).
(including totals for Column I Under Column K (right hand side of this form). Note. The first quarterly report of the
federal program year (October 1-December 31), the totals of Section I, Line #12 and Line #13 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 # 10.
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.
Page 4 of 5 ETA Form 9058 (Rev. August 2015)
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
Section K
Section K, Column (a). Enter the total number of W OTC certifications issued by the SW A during the
current report period, by starting hourly wage.1 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 #10.
Convert as follows:
Unit of Time Calculated Hourly W age
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.
1
According to the Fair Labor Standards Act (FLSA), the federal minimum wage is $7.25 per hour effective
July 24, 2009. Source: W age and Hour Division at the U.S. Department of Labor.
Page 5 of 5 ETA Form 9058 (Rev. August 2015)
Attachment 2
Official attachment: https://www.dol.gov/sites/dolgov/files/ETA/advisories/TEGL/2015/TEGL_09-15_Attachment_2.pdf
U.S. Department Labor OMB No. 1205-0371
Employment and Training Administration Expiration Date: August 31, 2018
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. August 2015)
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 or Empowerment Zone? Yes__ No
19. Do you live in an Empowerment Zone and are at least age 16, but not yet 18, on your hiring date? Yes __No
20. Did you receive Supplemental Security Income (SSI) benefits for any month ending within
60 days before you were hired? Yes No
21. 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
22. 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
23. 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.
24(a). Signature: (See instructions in Box 24.(b) for who signs this 24. (b) Signatory Options: Indicate 25. Date:
signature block) with a mark who signed this form:
Employer,
Consultant,
SWA,
Participating Agency,
Applicant, or
Parent/Guardian (if applicant is a
minor)
2 ETA Form 9061 – (Rev. August 2015)
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 (Box 24a.) 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 12-22. Applicant Characteristics. Read questions carefully, answer each question, and provide additional information where requested.
On January 2, 2013, President Obama signed into law the American Taxpayer Relief Act of 2012 retroactively authorizing the Empowerment Zones
(EZs) and WOTC non-veteran groups from December 31, 2011 through December 31, 2013. This Act also authorized continuation of the VOW Act
of 2011 expanded veterans and provisions through December 31, 2013. Form Updates. “Empowerment Zones” was added to Box 18 to capture
data for Designated Community Residents who must reside in a Rural Renewal County or EZ to be determined eligible for WOTC certification. A
new Box 19 was added to this form to capture information on the Summer Youth group activated when the EZs were reauthorized. Members of the
Summer Youth group must reside in an EZ to be determined eligible for WOTC certification. Boxes 19-21 were renumbered and are now Boxes 20 -
22. Box 22 below became Box 23, Sources to Document Eligibility.
Box 23 Sources to Document Eligibility. The applicant or employer is requested to provide documentary evidence to substantiate the YES answers in
Boxes 12 through 22. 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.)
2
QUESTION 12 Signed Letter of Separation or related document from
authorized Individual on DVA letterhead or agency stamp
Birth Certificate with specific description of months benefits were received.
Driver’s License For SWAs: To determine Ticket Holder (TH) eligibility, Fax
1
School I.D. Card page 1 of Form 8850 to MAXIMUS at: 703-683-1051 to
1
Work Permit verify if applicant: 1) is a TH, and 2) has an Individual Work
1
Federal/State/Local Gov’t I.D. Plan from an Employment Network.
Copy of Hospital Record of Birth
QUESTION 17
QUESTION 13
Parole Officer’s Name or Statement
DD-214 or Discharge Papers Correction Institution Records
Reserve Unit Contacts or Letters of Separation Court Records Extracts
Letter issued only by the Department of Veterans Affairs
(VA) on VA Letterhead or bearing the Agency Stamp, with QUESTIONS 18 & 19
signature, certifying Veteran status or that the Veteran has
a service-connected disability.
To determine if a Designated Community Resident (DCR)
lives in a Rural Renewal County, visit the site:
QUESTIONS 14 & 16
www.usps.com. Click on Find Zip Code; Enter & Submit
TANF/SNAP (Food Stamp) Benefit History Address/Zip Code; Click on Mailing Industry Information;
Signed statement from Authorized Individual with a specific Download and Print the Information, then compare the
description of the months benefits that were received county of the address to the list in the Instructions to IRS
Case number identifier Form 8850.
To determine if the DCR or a Summer Youth lives in an
QUESTION 15 Empowerment Zone, check the Instructions to IRS Form
8850, or visit the U.S. Department of Housing and Urban
Vocational Rehabilitation Agency Contact Development’s “locator” at: http://egis.hud.gov/ezrclocator/.
Veterans Administration for Disabled Veterans
3 ETA Form 9061 – (Rev. August 2015)
QUESTION 20 QUESTIONS 21 & 22
SSI Record or Authorization Unemployment Insurance (UI) Claims Records
SSI Contact UI Wage Records
Evidence of SSI Benefits
Box 24(a). Signature. The person who completes the form signs the signature block.
Box 24(b). Signatory Options. Qualified individuals/entities which can sign the form instead of the applicant: (a) Employer, (b) Consultant, (c) SWA staff, (d)
Participating Agency staff, (e) Applicant, or (f) Parent or guardian (If applicant is a minor, the parent or guardian must sign).
Box 25. 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.
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.
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 not a
valid piece of documentary evidence since May 1998.
4 ETA Form 9061 – (Rev. August 2015)
Attachment 3
Official attachment: https://www.dol.gov/sites/dolgov/files/ETA/advisories/TEGL/2015/TEGL_09-15_Attachment_3.pdf
U.S. Department Labor OMB No. 1205-0371
Employment and Training Administration Expiration Date: August 31, 2018
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. (See IRS Relief Period in TEGL No. 24-12 and IRS Notice 2013-14)
1. INITIATING AGENCY CODE (For Agency Use Only) 2. CONTROL NO.
(For Agency Use Only) Check “” 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 AND
GROUP NAME FOR HIRES OTHER
THAN “Veteran”:
11. ADDRESS (Street, City, State, Zip Code) &Telephone No. 12. VETERAN TARGET GROUP CODES (Check “” 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:
14. The above named individual may be eligible for certification Note. In the event you hire this individual, you should request the certification necessary for you
under the Work Opportunity Tax Credit. If individual is not to claim a Work Opportunity Tax Credit (WOTC). Simply complete and sign the Employer
employed before the date in the box below (Mo., Day, Yr.), this Declaration below, submit to the SWA this form together with IRS Form 8850 not later than
eligibility determination is subject to review. Applies to Summer April 29, 2013 for 1) members of the non-veteran target groups hired on or after January
Youth group only. 1, 2012 and on or before March 31, 2013, and for 2) qualified veterans hired on or
after January 1, 2013 and on or before March 31, 2013. For all hires after March
31, 2013, employers must meet the 28-day timely filing requirement. 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. August 2015)
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 individual 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 (PA), 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.
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 15. 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 target group. The non-veteran groups and the Empowerment
Zones were retroactively reauthorized through December 31, 2013 by the American Taxpayer Relief Act of 2013 signed into law by
President Obama on January 2, 2013. This Act also authorized the continuation of the VOW Act expanded veteran groups and
provisions through December 31, 2013.
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: Veteran 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 pre-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 only applies to the Summer Youth group.
Box 15: Name of Firm. Enter full name of the employing firm (the firm where the employee will actually work) and the address.
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.
Page 2 of 3 ETA Form 9062 (Rev. August 2015)
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 3 of 3 ETA Form 9062 (Rev. August 2015)
Attachment 4
Official attachment: https://www.dol.gov/sites/dolgov/files/ETA/advisories/TEGL/2015/TEGL_09-15_Attachment_4.pdf
U.S. Department Labor OMB No. 1205-0371
Employment and Training Administration Expiration Date: August 31, 2018
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 GROUPS’ CODES: (“” those that apply)
B2a. Qualified Veteran receiving SNAP benefits
B2b. Disabled Veteran
B2c. Disabled Veteran unemployed for 6 months
B2d. Veteran unemployed for 4 weeks but less than 6 months
11. NON-VETERAN TARGET GROUP CODE: B2e. 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 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) extended and amended the current veteran group, creating two
additional categories of unemployed veterans in Section 51 of the Internal Revenue Code, and making the WOTC available
to qualified 501 (c) 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, 2015.
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
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
target groups’ requirements.
Note. More information is available in the instructions for IRS Form 8850 & 5884, Work Opportunity Credit, for tax year 2015.
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. August 2015)
INSTRUCTIONS FOR COMPLETING AND ISSUING THE CERTIFICATION FORM (CF) ETA 9063.
Documentary evidence of eligibility and/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. Indicate, with a check mark ( “ “), which type of non-veteran target group is
being certified.
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. August 2015)
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