ETA-9057 Conditional Certifications

Conditional Certifications Issued U.S Department of Labor

Work Opportunity Tax Credit Program Employment and Training Administration

Summary Worksheet (For SWA Internal Use Only)

State:	Quarter Ending:	Control No. (For Agency Use Only)	OMB No. 1205-0371 Expiration Date: 8/31/09
I. By Issuing Agency	No. of Conditional Certifications Issued	II. By WOTC Target Group	No. of Conditional Certifications Issued
	WOTC		WOTC
1.Employment Service		12. IV-A Recipient
2. One Stop Career Center		13. Veteran
3. WIA LWIAs, Partner Agencies, and Training Providers		14. Ex-Felon
4. Voc. Rehab. Agencies		15. High-Risk Youth
5. Veteran Affairs Offices		16. Vocational Rehabilitation Referral
6. Welfare Offices		16.a. Ticket Holders
7. Social Security District Offices		17. Summer Youth
8. All Other Pas		18. Food Stamp Recipient
9. Employment Networks		19. SSI Recipient
		20. Long-Term Family Assistance Recipient
10. TOTAL (for quarter)		21. TOTAL (for quarter)
11. TOTAL (year-to-date)		22. TOTAL (year-to-date)
23. Name/Title of Responsible Official:	24. Signature:		25. Date:

Page 1 of 2 ETA Form 9057 (Rev. 12-28-06)

Instructions for Preparing ETA Form 9057 – Summary Worksheet (For SWA Internal Use Only)

ETA Form 9057 - Conditional Certifications Summary Worksheet for the Consolidated Work Opportunity Tax Credit and Participating Agencies (PA) is designed to summarize the number of Conditional Certifications (ETA Form 9062s) issued during each quarter by the SWAs/DLAs and the PAs. The summary worksheet should be prepared using data collected from ETA Form 9062.

This summary worksheet helps the SWAs in collecting quarterly data on conditional certifications for the WOTC Program.

The Summary Worksheet is divided into two sections. The first section, entitled "I. By Issuing Agency” collects the number of WOTC conditional certifications (CCs) issued by the SWAs/DLAs and all other Participating Agencies (boxes 1-9).

Where no CCs have been issued, please enter “0"

The second section, entitled "II. By WOTC Target Group,” collects the number of WOTC CCs issued by the different nine target groups (boxes 12-21).

Where no CCs have been issued, please enter "0."

The quarterly and year-to-date (cumulative) totals in Section I (boxes 10-12, respectively) should equal the quarterly and year-to-date (cumulative) totals in Section II (boxes 21-22, respectively).

Finally, the WOTC responsible official should enter/type his/her name in box 23 and affix his/her signature in box 24. Enter the date when the summary worksheet was prepared in box 25.

NOTE: This form no longer collects information on conditional certifications by type, i.e., by whether they are "original" or "revalidated" (Box 3 of ETA 9062). Therefore, counts of CCs in boxes 1-9 and 12-22 should not distinguish between original and revalidated CCs. For example, if in the first quarter of Fiscal Year 2006, an agency issued 70 original and 30 revalidated CCs, that agency issued 100 CCs. Note also that this form no longer reports invalidations of conditional certifications.

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 requirements is mandatory (P.L. 104-188). Public reporting burden for this collection of information is estimated to average1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to the U.S. Department of Labor, Division of Adult Services, Room C-4514, Washington, D.C. 20210 (Paperwork Reduction Project 1205-0371),

Page 2 of 2 ETA Form 9057 (Rev. Jan. 2007)