ETA-9061 Spanish V Individual Characteristics Form, Spanish Version

Individual Characteristics Form (ICF) U.S. Department of Labor

Work Opportunity Tax Credit Employment and Training Administration

Numero de Control (Para uso de la Agencia solamente)	Información del Solicitante (See instructions on reverse)		OMB No. 1205-0371 Fecha de Expiracion:
			Fecha en que la informacion fue recibida
INFORMACION DEL PATRONO
3. Nombre del Patrono	4. Direccion y Telefono del Patrono		5. Numero Federal ID (EIN) del Patrono
INFORMACION DEL SOLICITANTE
6. Nombre del Solicitante (Apellido, Primer, Inicial)	7. Numero Seguro Social		8. Ha trabajado para este patrono antes? Si ____ No ____ Si contesta Si provea fecha: _____________________
REQUISITOS QUE HACEN AL SOLICITANTE ELEGIBLE PARA CERTIFICACION BAJO WOTC
9. Fecha en que comenzo a trabajar	10. Salario		11. Posicion/Titulo
12. Tiene Ud., por lo menos 16 años, pero es menor de 40? Si ____ No ___ Si contesta SI, provea su fecha de nacimiento: ______________
13. Es Ud. un Veterano de las Fuerzas Armadas de los Estados Unidos de America (USA)? Si ____ No ____ Si contesta NO, llene el encasillado 14. Si contesta SI, es Ud. miembro de una familia que recibio beneficios de “Pan y Trabajo” (Aplica a Puerto Rico solamente) o que recibio Cupones para Alimentos (Food Stamps) for lo menos por 3 meses durante los 15 meses antes de ser empleado? Si __ No__ Si contesta SI, provea nombre del beneficiario prinicipal _______________________ y el nombre de la ciudad/estado donde recibio los beneficios _________________, O, es Ud un Veterano con derecho a beneficios por Incapacidad Fisicia relacionados con su servicio militar? Si ____ No ____ Si contesta SI, fue Ud. dado de baja del servicio activo militar un año antes de ser empleado? Si ___ No ___ O, estuvo Ud. desempleado por un periodo de por lo menos 6 meses durante el año antes de ser empleado? Si ____ No ____
14. Es Ud. miembro de una familia que recibio beneficios bajo el Program Pan y Trabajo (en P.R.) o Cupnones de Alimento durante los 6 meses antes de ser empleado? Si ____ No ____ O, recibio Cupones de Alimentos por un periodo de 3 meses durante los 5 meses antes de ser empleado pero ya no recibe estos beneficios? Si ____ No ____ Si contesta SI, a cualquiera de las preguntas, provea el nombre del beneficiario principal ________________________ y de la ciudad/estado donde los beneficios fueron recibidos______________________.
15. Fue Ud. referido a un patrono por una Agencia de Rehabilitacion Vocacional Estatal? Si ____ No ____ O, por un “Employment Network” bajo el programa “Ticket to Work” del Seguro Social? Si ____ No ____ O, por el Departamento de Asuntos del Veterano? Si ____ No ____
16. Es Ud. miembro de una familia que recibio asistencia TANF for 9 meses durante los 18 meses antes de ser empleado? Si ___ No___ Si NO, es Ud. miembro de una familia que recibio asistencia TANF por lo menos los ultimos 18 meses antes de ser empleado? Si __ No___ O, es Ud miembro de una familia que recibio asistencia TANF por cualquer periodo de 18 meses comenzando estos beneficios despues del 5 de agosto de 1997, y el ultimo periodo de 18 meses que comemzo despues del 5 de agosto de1997, termino 2 años antes de Ud ser empleado? Si ___ No ___ O, su familia no qualifico para asistencia TANF durante 2 años.antes de ser empleado pero una ley Federal o estatal limito el period maximo para Ud recibir esos pagos? Si ___ No ___ Si contesta SI, prova el nombre del beneficiario principal _________________________ y el nombre de la ciudad/estado donde los beneficios fueron recibidos _________________________.
17. Fue Ud. convicto por un delito o violacion y puesto en libertad despues de la encarcelacion durante el año antes de Ud ser empleado? Si ____ No ____ Si contesta SI, provea la fecha de apresamineto __________________ y la fecha de libertad por encarcelacion _________________________.
18. Vive Ud. en un “Empowerment Zone” o “Renewal Community?” Si ____ No ____ O, en un “Rural Renewal County (RRC)?” Si ____ No ____ Si contesta SI, provea el nombre del RRC _________________________.
19. Recibio Ud. beneficios de “Supplemental Security Income (SSI)” por cualquier mes que termino 60 dias antes de ser empleado? Si ____ No ____
20. Evidencia para documentar elegibilidad:
Certifico que esta informacion es veridica y correcta y entiendo que dicha informacion esta sujeta a verificacion.
21. Firma		22. Fecha

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 by the applicant, the employer or employer representative, the SWA/DLA, or the participating agency and signed by the individual completing the form. This form is required to be used, without modification, by all employers (or their representatives) seeking the WOTC.

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 so, enter a date or approximate date of employment.

Boxes 12-19. Applicant Characteristics. Read each question carefully, answer each question, and provide additional information where requested.

Box 20. Sources to Document Eligibility. The applicant or employer must provide documentary evidence to substantiate the YES answers on page 1. 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 Food Stamp agency stating to whom Food Stamp benefits were paid, the months for which they were paid, and the names of the individuals included on the grant for each month.

E xamples of Documentary Evidence and Collateral Contacts. You may check with your SWA to find out what other sources you can use to prove target group eligibility. (Please provide documentation or 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 Hospital Record of Birth

QUESTION 13

• SSI Record or Authorization

• DD-214

• Reserve Unit Contacts

• Discharge Papers

QUESTIONS 14 & 16

• TANF/Food Stamp Benefit

History

• Signed Statement from Authorized Individual w/Specific

Description of Months Benefits Were Received

• Case Number Identifier

QUESTION 15

• Voc. Rehab. Agency Contact

• Veterans Administration

• Records’ Signed Statement from Authorized Individual

w/Specific Description of Months Benefits Rec’d

• To Determine Ticket Holder (TH) Eligibility, Fax Page

1 of Form 8850 to MAXIMUS to Verify if Applicant:

1) is a TH, and 2) has an IWP from and Employment Network

QUESTION 17

• Parole Officer’s Name or

Statement

• Correction Institution Records

• Court Records’ Extracts

QUESTION 18

• Driver’s License

• Work Permit

• Utility Bills

Signed Statement from Authorized Individual w/Specific Description

• Lease Papers

• Voter Registration Card

• Food Stamp Award Letter

• Selective Service

• W-4

• Registration Card

• To determine if the address

of a DCR is in a Rural Renewal Community, visit the site: www.usps.com. Click on Find a Zip Code; Enter & Submit Address/Zip Code; Click on Mailing Industry Information; Download and Print the Information for Case File.

QUESTION 19

• SSI Record or Authorization

• SSI Contact

• Evidence of SSI Benefits

Note. * Where a Federal I.D. Card does not contain age or birth date, the SWA

must obtain another valid document to verify an individual’s age.

** Where a library card does not contain the holder’s address, the SWA must

obtain another document issued in the jurisdiction where the EZ/RC or RR

County is located showing the holder’s address.

In March 1998, an ETA directive, officially rescinded the authority to use Form I-9 as

proof of age and residence. Therefore the I-9 is no longer a valid piece of

documentary evidence.

Box 21. Signature. The person who completed this form must affix his/her signature here. If the applicant who completed the form is a minor, the parent or guardian must sign this box.

Box 22: 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 Adult Workers, Room C-4514, Washington, D.C. 20210 (Paperwork Reduction Project

1205-0371).

………………………………………………………………………………………………………………………………………………………………………………............. (Cut along dotted 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 THE SWA’s 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

3 ETA Form 9061 – June 2007