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Revised WOTC reporting and processing forms
Summary ETA transmitted revised Work Opportunity Tax Credit reporting and processing forms and instructions after the American Taxpayer Relief Act of 2012. It addressed state certification procedures and attached forms; Change 1 later corrected the formatting of Form 9061. ETA now labels this advisory Canceled.
Document
Federal guidance
Agency
U.S. Department of Labor, Employment and Training Administration (ETA)
Document number
TEGL No. 34-12
Date issued
June 14, 2013
Status
Withdrawn
ETA lists this advisory Canceled as of 2026-10-24; its PDF prints Expiration Date: Continuing and Rescissions: None. TEGL 34-12, Change 1 later corrected Form 9061. No cancellation instrument is identified.
Status last verified October 24, 2026
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Accessible letter PDF: https://www.dol.gov/sites/dolgov/files/ETA/advisories/TEGL/2013/TEGL_34_12_Acc.pdf
CLASSIFICATION
EMPLOYMENT AND TRAINING ADMINISTRATION WOTC
ADVISORY SYSTEM CORRESPONDENCE SYMBOL
U.S. DEPARTMENT OF LABOR OWI
Washington, D.C. 20210 DATE
June 14, 2013
ADVISORY: TRAINING AND EMPLOYMENT GUIDANCE LETTER NO. 34-12
TO: STATE WORKFORCE ADMINISTRATORS
STATE WORKFORCE AGENCIES
STATE WORKFORCE LIAISONS
FROM: Gerri Fiala /s/
Acting Assistant Secretary
SUBJECT: Work Opportunity Tax Credit (WOTC) Information Collection Revised Reporting
and Processing Forms
1. Purpose. To transmit revised WOTC reporting and processing forms to State Workforce
Agencies (SWAs), with instructions updated to reflect the new provisions in the American
Taxpayer Relief Act of 2012, and provide procedural guidance.
2. References.
• Sections 309 and 327 of the American Taxpayer Relief Act of 2012 (Pub. L. 112-240);
• Section 261 of the VOW to Hire Heroes Act of 2011 (Title II of Pub. L. 112-56);
• American Recovery and Reinvestment Act of 2009 (Pub. L. 111-5);
• Internal Revenue Code of 1986, Section 51, as amended;
• IRS Notice 2013-14 (March 7, 2013);
• IRS Notice 2012-13 (February 27, 2012);
• Training and Training and Employment Guidance Letter (TEGL) No. 24-12,
Reauthorization of the Work Opportunity Tax Credit Program and Continuation of the
VOW to Hire Heroes Act Veteran Groups and Provisions (May 1, 2013);
• TEGL No. 10-12, Guidance for Work Opportunity Tax Credit (WOTC) American
Recovery and Reinvestment Act of 2009 (Recovery Act) Two Expired Target Groups'
Applications (December 7, 2012);
• 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);
• 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); 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 WOTC program, enacted by the Small Business Job Protection Act of
1996 (Pub. L. 104-188) and Section 51 of the Internal Revenue Code (IRC), was created by
Congress as a tax credit incentive granted to those employers who provide employment
opportunities to members of a number of target groups, who have historically faced
significant barriers to employment.
On November 21, 2011, President Obama enacted the VOW to Hire Heroes Act of 2011
(VOW Act). Section 261 of the VOW Act, “Returning Heroes and Wounded Warriors Work
Opportunity Tax Credit,” made a series of amendments to the original veteran target group,
expanding the existing qualified veteran group, creating two types of unemployed veteran
groups, increasing the wages and specific tax credits for hiring certain veterans, and granting
WOTC to qualified tax-exempt organizations that hire these veterans. These changes and
provisions were to expire on December 31, 2012.
The legislative authority for all WOTC non-veteran target groups and for the Empowerment
Zones (EZs) expired on December 31, 2011, and subsequently reauthorized. Residence in
EZs is one of the criteria that determine eligibility for members of the Summer Youth and
Designated Community Resident (DCR) target groups.
4. New Legislative Provisions. On January 2, 2013, President Obama signed into law the
American Taxpayer Relief Act of 2012. Section 327 reauthorizes EZs and Section 309
reauthorizes the extension of the WOTC program.
In summary, this legislation:
• Continues the uninterrupted implementation of all veteran target groups, including
those implemented under the VOW Act through December 31, 2013.
• Retroactively reauthorizes all WOTC non-veteran target groups from December 31,
2011 through December 31, 2013.
• Provides legislative authorization for EZs from December 31, 2011 through December
31, 2013. (See TEGL No. 24-12 for more detailed information on the status of
EZs).
• Does not reauthorize the Recovery Act disconnected youth and Recovery Act
unemployed veteran target groups that expired at the end of 2010.
The new provisions required that three of five Employment and Training Administration
(ETA) WOTC program forms be revised to reflect the legislative changes. ETA requested
Office of Management and Budget (OMB) approval to make minimal, non-substantive
changes to 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;” and ETA Form 9062, “Conditional
Certification, Work Opportunity Tax Credit.” ETA received OMB approval to use the
revised forms attached to this TEGL.
5. Revised Forms and Instructions. ETA updated Forms 9058, 9061, and 9062 and their
instructions to reflect the new provisions introduced by Pub. L. 112-240 as follows: 1)
adding the Summer Youth group as a result of the retroactive reauthorization of the EZs, 2)
inclusion of the non-veteran target groups, which were retroactively extended, 3) information
about the continuation of the VOW Act veterans’ provisions, and 4) updating the revision
date from June 2012 to April 2013 at the bottom right-hand corner of each page. No changes
were required for ETA Form 9063, “Employer Certification,” and ETA Form 9065, “Audit
Summary Worksheet.” The specific changes are listed below.
I. ETA Form 9058 and Instructions
Form 9058 – “Certification Workload and Characteristics of Certified
Individuals”:
Page 1, Part II, Column I, By WOTC Target Group, Box 4. Summer Youth was
added since the legislative authority for EZs and the non-veteran groups that
expired on December 31, 2011 were reauthorized. Residence in EZs is one of the
criteria that determine eligibility for members of the Summer Youth and DCR
target groups.
Boxes 5-11 were renumbered without changes to the contents.
Instructions:
Page 2, Introductions, Line 3. Deleted “were added to.”
Page 2, Line 4. Deleted “and provisions.”
Page 2, Form Updates. The contents of this paragraph were updated by providing
a brief overview of Pub. L. 112-240 enacted by the President on January 2, 2013
and explaining the retroactive extension for the non-veteran target groups and the
EZs, the continuation of the VOW Act veterans’ provisions, and the updates to the
form required by these extensions.
Page 4, Section I. Added Line #4. “Enter the total number of WOTC
certifications issued by the SWA during the current report period for the Summer
Youth group.”
Page 4, Section I. Renumbered Lines #5 – 11 without any changes to the
contents.
Page 4, Section J, line 3 of the “Note”. Changed reference from “Line 9” to “Line
10.”
Page 5, Section K, Column (a), line 3 of the “Note”. Changed reference from
“Line 9” to “Line 10.”
II. ETA Form 9061 and Instructions
Form 9061 – “Individual Characteristics Form, Work Opportunity Tax Credit”:
Page 2, Box 18. Added “or Empowerment Zones” since DCRs can now once
again reside in EZs because these were reauthorized through December 31, 2013
by Pub. L. 112-240.
Page 2. Inserted a row and numbered it Box 19, to add the Summer Youth target
group now active since the EZs were reauthorized through December 31, 2013 by
Pub. L. 112-240.
Page 2. Renumbered all boxes below Box 18 (i.e., 19-25) without any changes to
the contents.
Instructions:
Page 3. Added 24(a) to the first paragraph.
Page 3, Boxes 12-22, Applicant Characteristics. Added information on the new
legislation and added a paragraph explaining the minor changes affecting the
form.
Page 4, “Examples of Documentary Evidence and Collateral Contacts.” Added
information on how to determine if the DCR or Summer Youth lives in an EZ.
III. ETA Form 9062 and Instructions
Form 9062 – “Conditional Certification”:
Page 1, Top Box titled: “EMPLOYERS.” Added this language: (See IRS Relief
Period in TEGL No. 24-12 and IRS Notice 2013-14), to alert employers and their
representatives about the filing relief from the statutory 28-day “timely filing
requirement.”
Page 1, Box 10. Adding language to clarify that both the code and group name
should be included for the non-veteran target groups.
Page 1, under NOTE TO EMPLOYER, Box 14. Added “Applies to the Summer
Youth group only.”
Page 1, under NOTE to EMPLOYER. Added language to reflect the new IRS
relief period from the 28-day filing requirement granted to employers when filing
certification requests on or before March 31, 2013.
Instructions:
Page 2, Line 4. Deleted the word “veteran” and replaced it with “individual.”
Page 2, Box 3, “For Ex-Felon Target Group Only.” Deleted the “Note” about Box
4 not applying to veterans hired under the VOW Act.
Page, 2, Box 5, “SWAs’ Name and Address.” Corrected the number cited from
“Box 16” to “Box 15.”
Page 2, Box 10, Target Group Code. Deleted the language instructing users that
the box does not apply because the groups expired on December 31, 2011.
Language was updated with information on the retroactive reauthorization of the
non-veteran groups.
Page 2, Box 12, Veteran Target Group Code. Added “veteran” to the name of the
box and the prefix “pre” to the word “certified.”
6. Transition Period for State Workforce Agencies and Employers. To ensure the smooth
and uninterrupted submission by employers of the certification requests for their new hires,
ETA is granting a transition period that allows employers to continue to file with the SWAs
the “old” ETA 9061 and 9062 forms from June 2012, for a temporary period. SWAs,
participating agencies, employers, and their representatives are encouraged to start using the
OMB-approved April 2013 versions of the revised ETA forms as soon as possible, and use of
these forms are required 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 Forms 9061 or Form 9062. During the 90-day transition period, SWAs must permit
employers to continue to use either the earlier June 2012 or the revised April 2013 versions
of Forms 9061 and 9062.
7. IRS Form 8850. On April 1, 2013, the IRS released a substantively unchanged Form 8850
and revised instructions for that form. The form and instructions are available at:
www.irs.gov/form8850.
8. Paperwork Reduction Act (PRA) of 1995 Notice and Reporting Authority. OMB
approved the reporting form, ETA 9058, and the two processing forms, ETA 9061 and 9062,
for the WOTC program, according to PRA, under OMB No. 1205-0371. This authority is
effective through June 30, 2015.
According to PRA, no persons are required to respond to a collection of information unless
such collection displays a valid OMB control number. The 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).
9. Action Requested. SWA administrators are requested to:
• Provide this TEGL and forms to all WOTC State Coordinators and related program staff,
employers and their representatives, participating agencies and other interested partners,
and
• Ensure the SWAs start using the revised OMB-approved forms within the timeframes
outlined in this guidance.
10. Inquiries. Direct all questions to the appropriate Regional WOTC Coordinator. A directory
with complete contact information is available on the WOTC program Web site at:
http://www.doleta.gov/business/incentives/opptax/Regional_Contacts.cfm.
11. 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”
All reporting and processing forms are also available on WOTC’s Web site at:
http://www.doleta.gov/business/incentives/opptax/forms.cfm.
Attachment 1: https://www.dol.gov/sites/dolgov/files/ETA/advisories/TEGL/2013/TEGL_34_12_Att1.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 is estimated to average 1 hour per response, including the time for reviewing instructions, Expiration
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of Information. Send comments regarding this burden Date: November 30, 2016
estimate or any other aspect of this information collection, including suggestions for reducing this burden to the U.S. Department of Labor, Employment and Training Administration,
Division of National Programs, Tools, &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.IV-A TANF Recipient Name-Code Name-Code 1. Under Federal
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
2Bc. DV Unemployed for 6 2. Business & Financial Operations – 13 3. $8.26 – $8.99
months 14. Bldg. & Grounds Cleaning &
Maintenance – 37
2Bd. V Unemployed for 4 15. Personal Care & Service - 39
weeks 3. Computer & Mathematical – 15 4. $9.00 -$9.99
2Be. V Unemployed for 6
months 4. Architecture & Engineering – 17 16. Sales & Related Occupations – 41 5. $10.00 – Higher
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. LTUR
11. TOTAL (For Qtr.)
12. 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. May 2016)
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 numbers during each reporting
quarter. Part II., continues to collect data on selected characteristics of certified individuals.
Form Updates. The Protecting Americans from Tax Hikes Act of 2015 introduced a new WOTC
target group, the Long-term Unemployment Recipient (LTUR), see Box 10.
Background. The purpose of ETA Form 9058 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. May 2016)
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 certification 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 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.
Page 3 of 5 ETA Form 9058 (Rev. May 2016)
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 total number of WOTC certifications issued by the SWA during the current report
period, for “Long-term Unemployment Recipients” (LTURs).
Section I, Line #11. Enter the sums of columns (a) and (b) and also the federal program current Quarter (For
Qtr.) Totals of columns (a) and (b) for Column I. “By WOTC Target Group;” and for Column J. “By
Occupation,” Line # 27. Total (For Qtr.) and for Column K. B y S t a r t i n g H o u r l y W a g e ” L i n e #
6 ( F o r Q t r . ) . Note. The first quarterly report of the federal program year (October 1-December 31), the
totals of Section I, Line #11 (For Qtr.) and Line #12 (YTD) should be the same. Also, the total (For Qtr.) of Part II,
Section I, Line #12, columns (a) & (b) should equal the total entered in Part I. Item E. Certified Requests.
Section I, Line #12. After Quarter 1, for all subsequent quarters enter the cumulative federal program
Year-to-Date (YTD) totals of columns (a) and (b). (including totals for Column I, Column J, and Column K (right
hand side of this form). R e m i n d e r . The first quarterly report of the federal program year (October 1-
December 31), the totals of Section I, Line #11 and Line #12 should be the same.
Page 4 of 5 ETA Form 9058 (Rev. May 2016)
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.
O*NET SOC JOB FAMILIES
Name Code Name Code
Food Preparation &
Management Occupations 11 35
Serving 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 55
Protective Service Occupations 33 Occupations
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.” Note. The TOTAL (For Qtr.) 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)
“Number Certified Individuals,” Line #11.
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. May 2016)
Attachment 2: https://www.dol.gov/sites/dolgov/files/ETA/advisories/TEGL/2013/TEGL_34_12_Att2.pdf
U.S. Department Labor OMB No. 1205-0371
Employment and Training Expiration Date: June 30, 2015
Administration
Individual Characteristics Form (ICF)
Work Opportunity Tax Credit
1. Control No. 2. Date Received
(For Agency use only) APPLICANT INFORMATION (For Agency Use only)
(See instructions on reverse)
EMPLOYER INFORMATION
3. Employer Name 4. Employer Address and 5. Employer Federal ID Number
Telephone (EIN)
APPLICANT INFORMATION
6. Applicant Name (Last, First, 7. Social Security Number 8. Have you worked for this
MI) 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 ___
6 ETA Form 9061 – (Rev. April 2013)
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___
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__
7 ETA Form 9061 – (Rev. April 2013)
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 23.(b) for who 24. (b) Signatory Options: Indicate 25. Date:
signs this signature block) with a mark who signed this form:
Employer, Consultant,
SWA, Participating Agency,
Applicant, or Parent/Guardian (if
applicant is a minor)
8 ETA Form 9061 – (Rev. April 2013)
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.)
QUESTION 12
Birth Certificate
Driver’s License
School I.D. Card
Work Permit
Federal/State/Local Gov’t I.D.
Copy of Hospital Record of Birth
QUESTION 13
DD-214 or Discharge Papers
Reserve Unit Contacts or Letters of Separation
Letter issued only by the Department of Veterans Affairs (VA) on VA Letterhead or bearing the Agency Stamp,
with signature, certifying Veteran status or that the Veteran has a service-connected disability.
QUESTIONS 14 & 16
TANF/SNAP (Food Stamp) Benefit History
Signed statement from Authorized Individual with a specific description of the months benefits that were received
Case number identifier
9 ETA Form 9061 – (Rev. April 2013)
QUESTION 15
Vocational Rehabilitation Agency Contact
Veterans Administration for Disabled Veterans
Signed Letter of Separation or related document from authorized Individual on DVA letterhead 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.
QUESTION 17
Parole Officer’s Name or Statement
Correction Institution Records
Court Records Extracts
QUESTIONS 18 & 19
To determine if a Designated Community Resident (DCR) lives in a Rural Renewal County, visit the site:
www.usps.com. Click on Find Zip Code; Enter & Submit Address/Zip Code; Click on Mailing Industry
Information; Download and Print the
Information, then compare the county of the address to the list in the Instructions to IRS Form 8850.
To determine if the DCR or a Summer Youth lives in an Empowerment Zone, check the Instructions to IRS Form
8850, or visit the U.S. Department of Housing and Urban Development’s “locator” at:
http://egis.hud.gov/ezrclocator/.
QUESTION 20
SSI Record or Authorization
SSI Contact
Evidence of SSI Benefits
QUESTIONS 21 & 22
Unemployment Insurance (UI) Claims Records
UI Wage Records
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).
________________________________
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.
10 ETA Form 9061 – (Rev. April 2013)
…………………………………………………………………………………………………………………………………………
(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.
11 ETA Form 9061 – (Rev. April 2013)
Attachment 3: https://www.dol.gov/sites/dolgov/files/ETA/advisories/TEGL/2013/TEGL_34_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. (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)
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.
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. April 2013)
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