Work Opportunity Tax Credit certification procedures

CLASSIFICATION
  EMPLOYMENT AND TRAINING ADMINISTRATION                 WOTC
              ADVISORY SYSTEM                            CORRESPONDENCE SYMBOL
         U.S. DEPARTMENT OF LABOR                        OWI-DNPTTA
            Washington, D.C. 20210                       DATE
                                                         March 31, 2021

ADVISORY:       TRAINING AND EMPLOYMENT GUIDANCE LETTER NO. 16-20

TO:             STATE WORKFORCE ADMINISTRATORS
                STATE WORKFORCE DEVELOPMENT AGENCIES
                STATE WORKFORCE LIAISONS
                STATE AND LOCAL WORKFORCE BOARDS AND CHAIRS
                STATE WORKFORCE OPPORTUNITY TAX CREDIT COORDINATORS
                AMERICAN JOB CENTERS

FROM:           SUZAN G. LEVINE
                Principal Deputy Assistant Secretary

SUBJECT:        Work Opportunity Tax Credit (WOTC) Procedural Guidance

1. Purpose. To provide updated procedural guidance to state workforce agencies (SWA) on the
   WOTC certification process. This Training and Employment Guidance Letter (TEGL) and
   the materials and forms it discusses supersede the guidance outlined in the Third Edition of
   Employment and Training Administration (ETA) Handbook No. 408, published in November
   2002, and its August 2009 Addendum.
2. Action Requested. This procedural guidance becomes effective three months from the
   issuance date of this TEGL. SWAs should update their processes and systems and
   administer the requirements outlined in this TEGL. SWAs must apply this guidance to all
   certification requests including any “backlog” unprocessed certification requests that were
   submitted for previous years. In the interim while SWAs are updating their processes and
   systems, SWAs should continue with the general WOTC application process according to the
   current policies and procedures that their state has in place and disseminate this information
   to all appropriate staff, employers, participating agencies, and other interested partners.
3. Summary and Background.
   a. Summary – This TEGL provides SWAs with updated procedural guidance for processing
      and issuing determinations for all WOTC certification requests for the current year and
      for unprocessed certification requests received in previous years. WOTC provides
      incentives for employers to hire individuals from certain targeted groups who face
      barriers to employment.

   b. Background – The WOTC is set forth under section 51 of the Internal Revenue Code of
      1986 (Code), as extended and amended by the Protecting Americans from Tax Hikes Act
      of 2015, Pub. L. No. 114-113, div. Q (PATH Act). WOTC is authorized until December
      31, 2020 (Section 143 of Division Q of P .L.116-94 -- Further Consolidated

 RESCISSIONS                                             EXPIRATION DATE
 None                                                    Continuing

       Appropriations Act, 2020). States can continue to review and prepare WOTC
       certification requests when there is a WOTC authorization lapse, but may not issue a
       certification. WOTC is available to eligible employers that hire first-time, qualifying
       members of WOTC targeted groups. Qualified tax-exempt employers described in
       section 501(c) of the Code and exempt from taxation under section 501(a) may claim the
       credit for hiring and employing first-time, qualified veterans. For more information on
       how to file for the tax credit and the eligible targeted groups, visit the Internal Revenue
       Service (IRS) website, http://www.irs.gov/wotc, and the ETA website,
       https://www.dol.gov/agencies/eta/wotc.

4. Details.

   Roles and Responsibilities. The U.S. Departments of Labor and Treasury jointly administer
   the WOTC. The roles and responsibilities are discussed below.
   a. U.S. Department of Treasury. The U.S. Department of Treasury, through IRS,
       administers all tax-related provisions of the WOTC.

   b. U.S. Department of Labor. The U.S. Department of Labor, through ETA, oversees the
      administration of the WOTC, including the allotment of grant funding to SWAs, which
      conduct the certification of qualifying members of targeted groups. To support
      adherence to the certification provisions set forth in the Code, ETA develops guidance,
      and provides technical assistance and training to ensure WOTC regional and state
      coordinators are apprised of legislative updates and equipped to adopt and implement
      procedural changes. The ETA Regional Offices provide federal oversight of the states'
      implementation of the WOTC.

       State Workforce Agencies. SWAs, which are the statutorily designated state agencies,
       are authorized to administer the operation of the WOTC certification process. The state
       coordinators and other Wagner-Peyser Employment Service staff process certification
       requests submitted by employers. States have various methods in place to accept
       certification requests depending on their level of funding, staff capacity, and type of
       system they use, including electronic submissions and by mail. Submission instructions
       can be found on the SWA’s websites. The SWA directory is available at:
       https://www.dol.gov/agencies/eta/wotc/contact.

       In addition, SWAs must administer the WOTC in accordance with the policies and
       procedural guidance set forth by ETA and requirements outlined in the WOTC Statement
       of Work (SOW). The SOW is included with annual WOTC Funding Allotment TEGLs.
       See TEGL No. 06-20, WOTC Initial Funding Allotments for Fiscal Year 2021 for a
       sample SOW. In subsequent years, refer to the most recent WOTC Funding Allotment
       TEGL for the current SOW.

   WOTC Certification Request Forms. SWAs use the IRS and ETA Forms below to process
   WOTC certification requests.
          IRS Form 8850, Pre-Screening Notice and Certification Request for the Work
           Opportunity Credit. This form is used by employers to pre-screen and to make a

             written request to their SWA to certify an individual as a member of a targeted group
             for purposes of qualifying for the WOTC. This form is to be used together with
             either the ETA Form 9061 (Individual Characteristics Form) or ETA Form 9062
             (Conditional Certification). In accordance with the instructions to IRS Form 8850,
             employers generally must submit the form to the SWA of the state in which the
             employer’s business is located (where the employee works) no later than the 28th
             calendar day after the member of a targeted group begins working for the employer.
             The IRS Form 8850 and instructions are available at: https://www.irs.gov/forms-
             pubs/about-form-8850. Additional information is available in the next section
             (WOTC Application Process, page 4) of this TEGL.

             Note: The IRS Form 8850 is strictly voluntary; therefore, the job applicant may
             refuse to complete the form with no adverse impact to securing employment. To
             report misuse of IRS Form 8850, contact the Treasury Inspector General for Tax
             Administration (TIGTA) by phone, fax, or an online form available at:
             https://www.treasury.gov/tigta/contact_report.shtml. TIGTA has independent
             oversight of IRS activities and is involved in the prevention and detection of fraud,
             waste, and abuse within the IRS and related entities.

            ETA Form 9061, Individual Characteristics Form. This form is used by employers,
             together with IRS Form 8850, to request certification of their employees under any
             targeted group. Additionally, ETA Form 9061 provides examples of supporting
             documentation that are accepted for each targeted group. The ETA Form 9061 is
             available at: https://www.dol.gov/sites/dolgov/files/ETA/wotc/pdfs/ETA-FORM-
             9061-(ENGLISH).pdf.

            ETA Form 9062, Conditional Certification. This form is used in place of ETA Form
             9061, together with IRS Form 8850, when the employee has been pre-certified as
             being a member of a specific targeted group by a participating agency.1 The ETA
             Form 9062 is available at:
             https://www.dol.gov/sites/dolgov/files/ETA/wotc/pdfs/ETA-Form-9062.pdf.

            ETA Self-Attestation Form (SAF) 9175, Qualified Long-term Unemployment
             Recipient (LTUR). This form is only used for LTUR certification requests. To
             facilitate processes used by SWAs to make eligibility determinations for the LTUR
             group, ETA created a national SAF. Only the individual seeking to be certified as a
             member of a targeted group should complete the SAF. The ETA Form 9175 is
             available at: https://www.dol.gov/sites/dolgov/files/ETA/wotc/pdfs/ETA-Form-
             9175.pdf.

1
 A "participating agency" is a federal, state, county, or local government agency or a grantee of these agencies. A
participating agency may include, but is not limited to, SWAs, American Job Center, WIOA grantees, School to-
Work Transition grantees, Vocational Rehabilitation agencies, city and county welfare offices, Veterans’ Affairs
offices, and other veterans’-service organizations.

       The WOTC processing forms are available at: https://www.dol.gov/agencies/eta/wotc/how-
       to-file/. ETA will update the dol.gov site with the Office of Management and Budget
       approved forms when there are legislative updates (for example, a required form for the
       addition of a new targeted group).

       Note: WOTC processing forms, including IRS Form 8850, ETA Forms 9061, 9062, and
       9175, are required to be used without modifications to the content and instructions. Forms
       must include any language related to a Privacy Act Notice, Paperwork Reduction Act Notice,
       or other notices and statements to ensure an applicant understands how the information
       provided on the form will be used and that completion of the form is voluntary.

       WOTC Application Process. To verify whether a job applicant is a member of a targeted
       group, ETA advises SWAs to use the following application process: 1) perform intake using
       ETA Forms; 2) verify that a job applicant is a first-time, qualifying member of a targeted
       group; and 3) notify the employer about the verification results, which include certification,
       denial, or denial pending more information.
       a) Intake Phase: During the intake phase, SWAs collect required forms and supporting
          documentation that are necessary to verify WOTC eligibility.
           SWAs should process certification requests that include an IRS Form 8850, Pre-
               Screening Notice and Certification Request for the Work Opportunity Credit, together
               with: 1) ETA Form 9061, Individual Characteristics Form, or 2) ETA Form 9062,
               Conditional Certification along with supporting documentation. SWAs have noted
               that receiving IRS Form 8850 separately from ETA Form 9061 or ETA Form 9062
               creates significant delay in the certification process. SWAs may inform employers of
               submission preferences, such as that submitting IRS and ETA WOTC Forms together
               results in timelier processing.
           SWAs may accept electronic signatures or ink signatures for the employer’s signature
               for IRS Form 8850 and ETA WOTC Forms used in the certification process. See IRS
               Notice 2012-13 for guidance on electronic signatures for IRS Form 8850 and for
               information on electronic submissions, which is available at:
               https://www.irs.gov/pub/irs-drop/n-12-13.pdf.
           In order to timely process a WOTC certification request, ETA recommends SWAs
               conduct an initial review of each certification request. The purpose of the review is to
               ensure that the certification request was submitted in a timely manner and is
               complete. Additional information about the initial review is available in the Initial
               Review section (page 9) of this TEGL.

       b) Verification Phase: Once an employer submits to the SWA a complete certification
          request, SWAs must determine whether an employee meets the requirements to be a
          member of the targeted group that the employer specifies on IRS Form 8850. State
          coordinators and other Wagner-Peyser Employment Service staff rely on the information
          provided on the IRS Form 8850 and either ETA Form 9061 or ETA Form 9062; if
          necessary, states can use supporting documentation and other available evidence to make
          decisions based on the documentation submitted.2 If the state determines that the

2
    Additional forms may be required for certain targeted groups (for example, a SAF for LTUR targeted group).

   employee is a member of the targeted group, the SWA will issue a certification using an
   ETA Form 9063. However, if the SWA is not able to determine whether the new hire
   meets the requirements for the targeted group(s), the SWA will issue a denial. The
   reasons for a denial vary, and may include that a new hire is not in a targeted group, or
   that a certification request was incomplete or included erroneous information.

   SWAs can develop working agreements with other SWAs for the timely and orderly
   processing of “out of state” certification requests, where SWAs provide available
   documentation and records for job applicants relocating and working in another state.
   SWAs can also establish formal agreements with appropriate state agencies and other
   partners to expedite verification of information employers submitted in the certification
   request, such as whether a new hire receives Temporary Aid to Needy Families, or was
   justice system-involved.

   Additional information about eligibility criteria and documentary evidence for targeted
   groups is listed in the ETA Form 9061 and the WOTC eligibility desk aid, which are
   available at: https://www.dol.gov/agencies/eta/wotc/how-to-file.

c) Notification Phase: SWAs must issue notifications to employers to inform them that
   their application was certified, denied, or denied pending more information in accordance
   with the Code and with this TEGL.
      SWAs must issue a Certification notification to an employer when a SWA
       determines that an employee is a member of the targeted group specified on IRS
       Form 8850.
      SWAs must issue a Denial notification to an employer when a SWA determines that
       an employee is not a member of the targeted group specified on IRS Form 8850. A
       denial notification must provide a basis for the denial.
      SWAs must issue a Denial Pending More Information notification, also known as
       an “Employer Needs” letter, when additional information is needed to complete a
       certification request. At minimum, an Employer Needs letter must: 1) set forth the
       additional information and/or documentation that must be submitted; 2) include a 90-
       calendar day deadline for the employers’ response; and 3) communicate that the
       certification request will be considered denied if the employer does not submit the
       additional information and/or documentation.

   Possible reasons for issuing a Denial notification

      Failure to meet IRS timely filing requirements. An employer did not submit a
       complete IRS Form 8850 to the SWA of the state in which an employer’s business is
       located (where the employee works) by the 28th calendar day after the employee
       began working for the employer. SWAs must not review an employer’s written
       appeal for a certification request that was not timely filed, unless the question of
       timely filing is the subject of the appeal.

       Note: States’ policies and procedures must adhere to the provisions in the Code and
       ETA guidance, and uphold the integrity of ETA’s WOTC certification process.
       SWAs must not allow employers to change the IRS Form 8850 after the 28th calendar
       day (for example, altering a certification request by adding new targeted groups or
       providing a different federal Employer Identification Number (EIN)).

      Does not meet eligibility requirements. If an employer’s certification request for an
       employee does not show that the employee meets the requirements to of the targeted
       group that the employer specified on IRS Form 8850, the SWA will issue a Denial
       notification. SWAs must adhere to the eligibility requirements and necessary
       supporting documentation for the targeted group as indicated on the ETA Form 9061
       and IRS Form 8850.

   Possible reasons for issuing a Denial Pending More Information notification

      Use of obsolete ETA Forms. SWAs may deny a certification pending more
       information if an employer submits a certification request using an obsolete ETA
       Form. If an employer requests verification for a targeted group that is no longer
       eligible and not listed on the ETA Form 9061, SWAs must issue a Denial Pending
       More Information notification that explains necessary corrective action. However,
       SWAs may process certification requests on older versions of ETA Forms if the
       targeted group is still active and shown on the form. When there is a legislative
       change in targeted groups, ETA will provide guidance to communicate the terms of a
       grace period, as needed.

      Incomplete certification request. SWAs may deny a certification pending more
       information if an employer submits an IRS Form 8850 without required supporting
       documentation or an ETA Form 9061 or ETA Form 9062.

      Incomplete ETA Forms. SWAs may deny a certification pending more information
       if an employer submits an incomplete ETA Form, e.g., missing information or
       missing signature.

Authorized Representative. An employer may choose to authorize an individual to
represent them for WOTC purposes by submitting an IRS Form 2848, Power of Attorney and
Declaration of Representative, to a SWA. Without being listed on the IRS Form 2848, a
representative cannot facilitate the employer’s certification requests nor submit Form(s) 8850
on behalf of the employer. SWAs may request that employers attach an IRS Form 2848 with
each individual or set of certification requests. In cases where an employer does not submit
an IRS Form 2848 with each individual or set of certification requests, a SWA may use the
IRS Form 2848 that is on file for that employer and EIN. SWAs should not conduct any
WOTC business with an individual who is not listed as an authorized representative on an
employer’s IRS Form 2848 that is on file. SWAs should not accept an IRS Form 2848
signed and dated after the WOTC certification request is submitted to the SWA. Note: The
IRS has not at this time issued any guidelines or information granting approval for e-signing
or e-filing the IRS Form 2848.

An authorized representative is authorized to act on behalf of the employer regarding the
certification process, which includes but is not limited to:
 Submission of IRS Form 8850 and ETA Forms 9061 or 9062;
 Submitting missing information that is necessary for a certification request;
 Providing updates or clarifying information regarding an employer’s certification request;
    and
 Providing copies of any notices related to an employer’s certification request. This
    authorization will automatically terminate three years from the date it is signed unless
    revoked or withdrawn earlier.

Authorized representatives should not make changes to the information provided by an
employee after both the employee and employer have signed IRS Form 8850. If the SWA
believes the employee information provided on the IRS Form 8850 has been modified
without the consent of the employee/and or the employer, the SWA should follow its
procedures to request additional or clarifying information from the employee and/or the
employer.

SWAs should send notices and communications to employers. SWAs can also send notices
and communications to authorized representatives if the SWA has an IRS Form 2848 on file
at the time the employer requests certification, and if the employers checked box 2 of the
form titled “Representative(s) Check if to be sent copies of notices and communication.”
However, if the SWA does not have an IRS Form 2848 on file at the time of the certification
request submission, or the form on file does not have box 2 checked as described above, the
SWA should send all notifications directly to the employers.

For more information on the IRS Form 2848, see https://www.irs.gov/forms-pubs/about-form-2848.

Employer Appeals. After an employer receives a denial from a SWA for a complete, timely
filed certification request, an employer may submit a written appeal to the SWA within one
year from the date the SWA issued the denial letter. ETA recommends that SWAs
communicate clearly with employers about what information will be useful in an appeal, e.g.
an explanation of why the employer believes an incorrect denial was issued, any clarifying
information that was not submitted with the original certification request, or an explanation
of where the employer believes the SWA misinterpreted information. If an employer
disagrees with a SWA’s decision on an appeal, employers can submit an appeal in writing to
the ETA Regional Administrator for a determination with supporting documentation. The
ETA Regional Office will issue the final determination on the matter. The contact
information is available on the WOTC website at:
https://www.dol.gov/agencies/eta/wotc/contact.

Note that this appeal process has changed from the process specified in ETA Handbook 408.
In particular, the previous process allowed for an additional level of review in the ETA
National Office in instances where the employer found the ETA Regional Office’s
determination unsatisfactory. ETA will no longer review its own decisions; the ETA

Regional Offices are well situated to make final determinations regarding specific WOTC
appeals.

Workflow Process to Eliminate Backlog. Many states have adjusted their certification
processes to both process current year submissions and to eliminate their backlog of
certification requests not yet processed. SWAs that have successfully adjusted their
processes and devote staff time to both often focus the backlog portion of time on
certification requests that are complete and for which the three-year statute of limitations
generally applicable to tax years will soon end, then process backlogged requests from
previous years, when time and resources permit.

WOTC Performance Reporting and Administrative Forms for SWAs. SWAs use the
forms below for administration purposes:
   ETA Form 9058 - Report 1, Certification Workload and Characteristics of Certified
    Individuals. This form collects program activity by the SWAs and is submitted to the
    ETA on a quarterly basis. Although SWAs may add their logos, this form is required to
    be used without modifications to the content and instructions.

   ETA Form 9065, Work Opportunity Tax Credit, Audit Summary Worksheet. This
    worksheet is an optional ETA form for SWAs’ internal use in recording the results of
    verification activities conducted by each SWA. States are not required to submit this
    form to ETA. The form’s design and format are optional, and states can change the
    design and format.

   ETA Form 9063, Employer Certification, and its Instructions. The SWA issues this form
    to an employer or representative to inform the employer that the employee has been
    certified to be a member of the targeted group requested, and can only issue it after
    verifying targeted group eligibility. If audited, employers should provide this
    certification to the IRS. The contents of this form cannot be modified by a SWA, but
    states can modify its design or appearance. Given the purpose of this form, it is the only
    WOTC form not accessible online. ETA directly supplies this form to SWAs; SWAs can
    contact their WOTC Regional Coordinators for the form if needed.

With the exception of ETA Form 9063, these current ETA Forms are available at:
https://www.dol.gov/agencies/eta/wotc/resources. Note that these forms are available for use
by SWAs only.

Recordkeeping for SWAs. States must keep copies (hard copy or electronic) of IRS Forms
8850, ETA Forms 9061, ETA Forms 9062, ETA Forms 9063, denial letters, supporting
documentation, and any other forms relating to certification requests for a minimum of three
years after issuance or rejection of the certification. IRS publishes guidance to employers on
their record-keeping responsibilities. SWAs can share such information with employers. For
information about recordkeeping, see the instructions to IRS Form 8850, which are available
at: https://www.irs.gov/forms-pubs/about-form-8850. SWAs can also find information on
recordkeeping in IRS Publication 583 “Starting a Business and Keeping Records, which is

available at: https://www.irs.gov/businesses/small-businesses-self-employed/how-long-should-i-keep-records.

Initial Review. ETA recommends SWAs conduct a review of each certification request as a
quality control method. During the initial review, the SWA should determine if the
certification request was timely filed and complete. ETA recommends SWAs record the
initial review in the applicant’s file, including the name of the reviewer, type of certification
method (that is, automated or manual system), and the date it was completed.

Quarterly Audit. To reduce the chances of erroneously certifying ineligible persons for
WOTC, SWAs must conduct quarterly audits. A quarterly audit is a verification activity to
examine the quality of the SWA’s certification process. In a quarterly audit, ETA
recommends SWAs review certifications for the following:
 Timely submission;
 Completeness of forms (for example, signatures and dates);
 Use of available data (for example, Unemployment Insurance Wage Records, etc.);
 Accuracy of copies of supporting documentation; and
 Forms were submitted by the employer or the employer’s authorized representative.

If a SWA issues an incorrect denial, SWAs must re-determine the certification request and,
where the request meets requirements, issue a certification. If the SWA issued an incorrect
certification, SWAs must revoke the certification.

For those applications found to be ineligible, the SWA must issue a notice of invalidation
(NOI) or notice of revocation (NOR) based on the review of certifications. SWAs should
send the NOI to the employer, participating agency, and job applicant invalidating an
incorrect ETA Form 9062, Conditional Certification, notifying them that the Conditional
Certification is invalid due to missing or incorrect information. For a sample NOI, see
Attachment I.

SWAs should send the NOR to an employer, an authorized representative where appropriate,
and the IRS. An NOR should communicate to the employer the reason why the SWA was
not able to determine that the employee is a member of a targeted group, and the effective
date of the revocation. The NOR should also inform affected employers that wages paid to
the “non-eligible” employee cannot continue to be treated as “qualified wages” for WOTC
purposes. For a sample NOR, see Attachment II. There are some cases when IRS will
contact ETA or a SWA to request that the SWA issue a written NOR based on the IRS’
review of certifications.

SWAs can transmit the NOR to IRS at the following IRS fax number:
   Internal Revenue Service
   Small Business/Self-Employed Campus Compliance Services
   Fax: 1-855-242-6540

Note: It is not the responsibility of the SWAs to verify that an employee certified to be a
member of a targeted group has worked the required number of hours for the employer,

   under section 51(i)(3) of the Code. SWAs are only responsible for verifying and certifying
   an applicant’s eligibility as a member of a targeted group. The responsibility for verifying
   the required number of hours worked rests with the IRS.

5. Inquiries. Please direct all questions to the appropriate Regional WOTC Coordinator, listed
   on the WOTC website at: https://www.dol.gov/agencies/eta/wotc/contact.
6. References.
       Training and Employment Guidance Letter 25-15, Change 2, Work Opportunity Tax
         Credit 2015 Reauthorization , dated February 16, 2018; and
       Section 51 of the Internal Revenue Code (26 U.S.C. §51) available at
         https://uscode.house.gov/view.xhtml;jsessionid=36D3880A571F8263FD07D4406A9
         C774E?hl=false&edition=prelim&req=granuleid%3AUSC-1995-title26-
         section51&num=0.

7. Attachments.
   Attachment I: Notice of Invalidation (NOI)
   Attachment II: Notice of Revocation (NOR)

                                                                                               Attachment I
 Sample Invalidation Notice: The NOI notifies the Participating Agency (PA), applicant, and the
 employer/consultant to whom the applicant was referred that the Conditional Certification (CC) (ETA Form
 9062) is INVALID because of missing or incorrect information/items.

                                  Notice of Invalidation (NOI)
                            Work Opportunity Tax Credit Certification

Date:           ___________________________________
Address:        ___________________________________
                ___________________________________
The employee referenced below was certified as meeting the eligibility requirements for the
Work Opportunity Tax Credit. However, a subsequent review revealed the employee is
ineligible for Work Opportunity Tax Credit.
Employee Name:           ______________________________________
Employee SSN:
                         (Enter last four digits of employee’s SSN)
Employee Address: ______________________________________
                         ______________________________________

Certification #:         ______________________________________
FEIN# / Company:
Start Date:              ______________________________________
Target Group:            ______________________________________

Accordingly, this correspondence is to inform you that the certification is invalidated, effective
upon receipt of this notice. A copy of this notice has also been forwarded to the Internal
Revenue Service (IRS) for their records.
Sincerely,

Authorized SWA Official’s Signature
Printed Name
Title
cc:

                                                I-1                                 Updated February 2021

                                                                                     Attachment II

                             NOTICE OF REVOCATION (NOR)
                            Work Opportunity Tax Credit Program

      (Sample Revocation Notice to be sent to Employer and IRS – Return Receipt Requested)

Employer’s Name: _____________________
Federal Employer Identification Number (EIN):     -
Address: _____________________________
_____________________________________
_____________________________________

New WOTC Certified Employee’s Name: _____________________________
Employee’s Social Security Number (SSN):

                                         (Enter last four digits of employee’s SSN)
Employee’s Address: ___________________________________________
_____________________________________________________________
_____________________________________________________________

On ____________________ the individual identified above was certified as meeting the
  (Enter date of certification)
requirements of a member of target group ______________________________ for the Work
                                                  (Enter target group name)
Opportunity Tax Credit (WOTC) under Section 51 of the Internal Revenue Code. Subsequent
review reveals that the certification was incorrect.

Accordingly, the certification is revoked and wages paid by you to the individual after you
receive this notification cannot be treated as qualified wages for WOTC purposes, and are
therefore not eligible for the tax credit. A copy of this notice is being sent to the Internal
Revenue Service.

________________________________                              ___________________________
(Authorized SWA Official’s Signature)                                     (Date)

cc:     Internal Revenue Service

        Participating Agency
        Address
        SWA File

                                           II-1                             Updated February 2021