ETA-9061 Individual Characteristics

Individual Characteristics Form U.S. Department of Labor

Work Opportunity Tax Credit Employment & Training Administration

1. CONTROL NO. (For Agency Use Only)	Individual Information (Instructions on the Back)					OMB No. 1205-0371 Expires: 8/31/09
						2. DATE RECEIVED (For Agency Use Only)
3. EMPLOYER NAME/ADDRESS:		4. EMPLOYER FEDERAL ID NO.		5. EMPLOYMENT START DATE:: Starting Wage: $_________________ per hour POSITION:
		6. Have you worked for the above employer before? Yes_____ No_____ If Yes, enter date and year: _____________
7. NAME OF INDIVIDUAL (Last, First, Middle): Fgfdfgd				8. SOCIAL SECURITY NUMBER:
The above named individual is determined to have the following characteristics for WOTC target group certification:
9. Is your age between 18 – 40? Yes_____ No_____ If YES, indicate your "Date of Birth" below: Date of Birth: ______________________		10. Is a veteran and a member of a family that received Food Stamps for a period of at least 3 months in the last 15 months. Yes_____ No_____ If YES, also complete Box 17.		11. Is a member of a family that received TANF benefits for any 9 months in the last 18 months. Yes_______ No_______ If YES, also complete Box 17.
12. Is a member of a family that received Food Stamps for the last 6 months. Yes_______ No________ , or for at least a 3-.month period within the Iast 5 months, BUT is no longer receiving them. Yes_______ No______ If YES to either, also complete Box 17.		13. In the past year, individual has been convicted of a felony or released from prison after a felony conviction. Yes______ No_______ If YES, complete below: Date of Conviction _______________ Date of Release ________________		14. Lives and plans to continue living in a federal Empowerment Zone, Enterprise Round II or Renewal Community. Yes ________ No ____ ______________________________________ 16. Received Supplemental Security Income (SSI) benefits for any month ending within the last 60 days. Yes_________ No_______
15. Is receiving or has received Rehabilitation Services through a State Rehabilitation Services’ program or the Veterans' Administration. Yes_______ No________
				17. If individual is not a primary recipient of benefits, please provide the following: _____________________________________ Name of Primary Recipient _____________________________________ City/State of Benefits
18. Is a “ticket holder” under the Ticket to Work Program Yes _________ No _________			19. The “ticket holder” has an Individual Work Plan (IWP) from an Employment Network (EN). Yes _______ No ______
20. Is a member of a family that:: Has received/is receiving TANF payments for at least the last 18 consecutive months; Yes ____ No ____ or Has received/is receiving TANF payments for any 18 months starting after August 5, 1997; and the earliest 18-month period beginning after August 5, 1997, and ended within the last 2 years; or Yes ______No or Stopped being eligible for TANF payments within the last 2 years because Federal or state law Yes _____ No ____ limited the maximum time those payments could be made, and having a hiring date not more than 2 years after the date of cessation of TANF benefits.
21. SOURCES USED TO DOCUMENT ELIGIBILITY:
Note: I certify that the Information is true and correct to the best of my knowledge. I understand that the information above may be subject to verification. The signature of the party completing this form is required below. If applicant is a minor, the parent or guardian should sign this box.
22. SIGNATURE:					23. DATE:

Page 1 of 3 ETA Form 9061 (Rev. Dec. 2006)

INSTRUCTIONS FOR COMPLETING THE INDIVIDUAL CHARACTERISTICS FORM (ICF), ETA 9061. This form is used together with IRS Form 8850 to help SWAs determine eligibility for the consolidated Work Opportunity Tax Credit Program. The form may be completed by the applicant, the employer or employer representative/consultant, the SWA/DLA or the Participating Agency and signed by the person or agency filling out this form. This form is required to be used, without modification, by all employers and/or their representatives seeking the WOTC.

Box 1: Control Number (for agency use only). The SWA/DLA or participating agency determines the Control Number. It may be a Social Security Number, case number, or other appropriate designation which permits easy filing, identification and retrieval of forms. Enter this number here.

Box 2: Date (for agency use only). Enter the month, day, and year when the form is received.

Box 3: Employer Name/Address. Enter the name and address including zip code and telephone number of the employer applying for a WOTC Employer Certification.

Box 4: Employer Federal ID No. Enter employer's federal taxpayer identification number.

Box 5: Employment-Start Date//Wage/Position or Title. Enter the employment start date, the starting hourly wage, that the employee will be paid. If not known, enter an estimated wage. Also, enter the job or position title, under which the individual or prospective employee will be performing for this employer.

Box 6: Previous Employment for This Employer. This requires a YES or NO answer. Enter a check mark (  ) in the corresponding blank. If Yes, enter date and year.

Box 7: Name of Individual. Enter full name of Individual or prospective employee.

Box 8: Social Security Number. Enter individual's social security number here.

Boxes 9 through 20 (Read each box carefully). Enter a check mark ( ) to indicate If your answer is a YES or a NO. Provide additional information where requested for the WOTC target group eligibility.

Box 21. Sources to Document Eligibility. List or describe the documentary* evidence or sources of collateral contacts that are attached to the ICF form or that will be provided. Indicate in parentheses, next to each document listed, whether it is attached or forthcoming. Some examples are provided below. Employers may also obtain a letter from the agency that administers a relevant program, stating that the employee or a member of his/her household meets one of the eligibility requirements.

Examples of Documentary Evidence or Collateral Contacts:

­ AGE/BIRTHDATE: VOC REHAB (Continued) EZ/EC/RCs (Continued)

(Required for High-Risk

Summer Youth & Food Stamp)

• Birth Certificate

• Driver’s License

• School I.D. Card*

• Work Permit

• Federal/State/Local Gov’t I.D.*

• Hospital Record of Birth

FAMILY INCOME:

(Required for Ex-felon)

• Pay Stubs

• Employer Contacts

• W-2 Forms

• UI Documents

• Public Assistance Records of No. of Months Benefits Were Received.

• Family Members’ Statements

• Parole Officer’s Name

• Parole Officer’s Statements

SSI RECIPIENT:

• SSI Record or Authorization

• SSI Contact

• Evidence of SSI Issuance

EX-FELON STATUS:

• Parole Officer’s Name

• Correction Institution Records

• Court Record, Extracts

TANF (IV-A) RECIPIENT:

• TANF Benefit History

• Signed Statement from Authorized Individual w/ Specific Description of Months Benefits Were Received.

• Case Number Identifier

NUMBER IN FAMILY

• Public Assistance

• Social Services Agencies

VETERANS’ STATUS:

• DD-214

• Reserve Unit Contacts

• Discharge Papers*

VOCATIONAL REHABILITATION REFERRAL:

• Voc. Rehab. Agency Contact

• Signed statement from authorized individual w/specific description of months benefits received

• Veterans Administration Records

LONG-TERM FAMILY ASSISTANCE RECIPIENT

• TANF Benefits History

• Signed Statement from authorized individual with specific description of months benefits received

• Case Number Identifier

EMPOWERMENT ZONES/ENTERPRISE/

RENEWAL COMMUNITIES:

• Driver’s License

• Work Permit

• Utility Bills

• Signed Statement From Authorized Individual w/ Specific Description

• Lease Document

• Voter Registration Card

• Food Stamp Award Letter

• Social Security Agency Letter

• Library Card**

• Landlord’s Statement

• Letter From Social Service Agencies

• School Records

• Medicaid/Medicare Card

• Property Tax Record

• Public Assistance Record

• Rent Receipts

• School I.D. Card**

• W-4

• Selective Service Registration Card

TICKET HOLDER (Ticket to Work Program)

• SWAs must establish applicant’s eligibility by calling MAXIMUS to verify if applicant: 1) is a ticket holder and 2) has and IWP from an Employment Network (EN).

NOTE: This list is not an exhaustive list. For more information, contact your WOTC public State Workforce Agency.

*Where any item of documentation such as a Federal I.D. Card does not contain age or birth date, the SWA/DLA must obtain another documentary source to verify the individual’s age.

**Where any item of documentary evidence, such as library card does not contain the holder’s address, the SWA/DLA must obtains documentary evidence issued in the jurisdiction where the EZ/EC or RC is located showing the holder’s address.

Page 2 of 3 ETA 9061 (Rev. Dec. 2006)

22. Signature. Affix your signature.

23. 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 requirements is required to obtain and retain benefits per P.L. 104^.184. 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 intonation. 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).

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(Cut along doted line and keep in your files)

TO THE JOB APPLICANT OR EMPLOYEE:

THE INFORMATION AND THE SUPPORTING DOCUMENTATION YOU HAVE PROVIDED IN COMPLETING THIS FORM —OR IN SOME CASES OTHER INFORMATION THAT COULD VERIFY THE RESPONSES YOU HAVE GIVEN TO THE ITEMS/QUESTIONS IN THIS FORM— WILL BE DISCLOSED BY YOUR EMPLOYER TO THE STATE WORKFORCE AGENCY (SWA) [ENTER CORRESPONDING SWA NAME BELOW:

_________________________________________________________________________________________

IN ORDER TO QUALIFY FOR A FEDERAL EMPLOYER TAX CREDIT, 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 9061 (Rev. Dec. 2006)