ETA-9062 Conditional Certification

Conditional Certification U. S. Department of Labor

Work Opportunity Tax Credit Employment & Training Administration

			OMB No. 1205-0371 Expiration Date: 8/31/09
1. INITIATING AGENCY CODE (For Agency Use Only) CODE: ___________ ______ Participating Agency______ SWA/DLA			2. CONTROL NO. (For Agency Use Only) CONTROL NO. _______________ ____ Participating Agency ____ SWA/DLA				3. TYPE OF CONDITIONAL CERT. (“” One) (For Summer Youth ONLY) a.  Original b.  Revalidation
4. FOR EX-FELON TARGET GROUP ONLY. a. Conviction/Release Date: ___________________ b. Corrections Institution ID No:___________							5. DATE COMPLETED (Mo., Day, Yr.) _________________
6. State Workforce Agency’s Name and Address		7. SIGNATURE (Authorized Official)					8. TELEPHONE NO.
PART I. INTRODUCTION
9. NAME OF INDIVIDUAL (Last, First, Middle)						10. SOCIAL SECURITY NO.
11. ADDRESS (Number, Street, City, State, Zip Code)				12. TARGET GROUP CODE (“” One)  Ticket Holder (TH)  With Individual Work Plan from an Employment Network, or a Summer Youth (SY) Enter Code if not a TH or SY:_______________
14. APPLICANT’ SIGNATURE:
NOTE TO EMPLOYER:
1 5. The above named individual may be eligible for certification under the Work Opportunity Tax Credit. If not employed before the date in the box below (Mo., Day, Yr.), this eligibility determination is subject to review.				In the event you hire this person, you should request the certification necessary for you to claim a Work Opportunity Tax Credit. Simply, complete and sign the Employer Declaration below, mail to the SWA or Designated Local Agency together with the PSN-IRS Form 8850, not later than the 28th day after the applicant starts work. The WOTC Employer Certification Form 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:
I, HEREBY, DECLARE that the above named person was or will be employed by:
16. NAME OF FIRM:	17. POSITON/JOB TITLE:				18. EMPLOYMENT-START DATE: (Mo., Day, Yr.)			19. STARTING WAGE: $ _________ per hour
Please send a WOTC  certification for this employee. The certification is for the purpose of obtaining benefits of the WOTC, under Sec. 51 of the Internal Revenue Code. Employers are advised that such credit will cease immediately upon notification of any subsequent invalidation. Employers are further advised that if the certification herein requested is for a member of the SUMMER YOUTH target group, the tax credit for which he/she may be eligible is subject to the limits described at Sec. 51 (d)(7) of the Internal Revenue Code.
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.
20. EMPLOYER’S NAME AND SIGNATURE								21. DATE
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CONDITIONAL CERTIFICATION (CC) ETA FORM 9062. When a SWA/DLA or Participating Agency (PA) determines that a job-ready applicant is, tentatively, ELIGIBLE as a member of a target group for the consolidated WOTC, it shall use this required form, without modification, to show that an eligibility 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 person is hired, and provides a means for employers to request a WOTC certification for this person.

INSTRUCTIONS FOR COMPLETING THE “CONDITIONAL CERTIFICATION” FORM. (Boxes 1-15 are for participating agency and SWA/DLA use only)

Box 1: Initiating Agency Code. If the CC was issued by a participating agency (PA), enter its code. SWAs/DLAs 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/DLA, enter the SWA/DLA code, if available. Indicate with a check mark “” if initiating agency is a Participating Agency or SWA/DLA.

Box 2: Control Number. Usually the PA determines the control number (CN). However, SWAs/DLAs may, for internal control purposes, develop their own CN system. It may be a Social Security No., case no., or some other appropriate 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/DLA.

Box 3: Type of Conditional Certification. This system distinguishes between “Original,” if the individual is being processed for the first time, or “Revalidation,” if the eligibility process was performed within the previous 12-month period, (e.g. , 45 days for the Summer Youth target group only). Otherwise, the Conditional Certification is counted as “Original.” Indicate with a check mark “” whether eligibility determination is “Original” or “Revalidation.”

Box 4: For Ex-Felon Target Group Only. For items a - c, enter the corresponding information. This information will help you in verifying target group eligibility.

Box 5: Date Completed. Enter the month, day, year in which the eligibility determination was completed.

Box 6: SWA/DLA Name and Address. (If known, enter or stamp the name and address, including zip code, of the SWA/DLA responsible for Certifications requests for the employer indicated in Box 16. Leave blank if SWA/DLA’s name and address is unknown.

Box 7: Signature. Enter signature of the authorized conditionally-certifying official.

Box 8: Telephone No. Enter corresponding SWA/DLA or participating agency area code, telephone number and extension, if available.

PART I. INTRODUCTION:

Box 9: Name of Individual. Enter the individual’s/applicant’s full name (i.e., last name, first name and middle initial).

Box 10: Social Security Number. Enter the individual’s/applicant social security number.

Box 11: Address/Telephone No. Enter the individual’s/applicant’s home address, including apartment number and zip code. After address, enter individual’s/applicant’s telephone number, including area code.

Box 12: Target Group Code. Enter a check mark “” to indicate if “Summer Youth, “Ticket Holder (TH)” with an IWP from an Employment Network (EN) or Other.” If different from Summer Youth or Ticket Holder, enter code for specific WOTC target group based on client’s information and documentation provided.

Box 13: Group Code. Enter a check mark “” to indicate if “Long-Term Family Assistance Recipient”, and enter its code based on client’s information and documentation provided.

Box 14: Signature. Get Individual’s/applicant’s signature. If a minor, parent or guardian must sign here.

Box 15: CC Validity Period. (This box is to be completed by the SWA/DLA or PA). Enter the month/day/year when the CC expires

(e.g. 45 days for Summer Youth)

Page 2 of 3 ETA Form 9062 (Rev. Dec. 2006)

PART II. EMPLOYER DECLARATION:

Box 16: Name of Firm. Enter full name of the employing firm (the firm where the employee will actually work).

Box 17: Position/Job Title. Enter the position or job title the employee will hold.

Box 18: Employment-Start Date. Enter the date the employee began or will begin work for the employing firm.

Box 19: Starting Wage. Enter the wage or salary which the employee will be paid. If not known, enter an estimated wage.

Box 20: Employer’s Name and Signature. Enter employer’s corresponding 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 requirements 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, Division of Adult Services, Room C-4514, Washington, D.C. 20210 (Paperwork Reduction Project 1205-0371)

Page 3 of 3 ETA 9062 (Rev. Dec. 2006)