Eta 9061

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

Work Opportunity Tax Credit Employment and Training Administration

Control Number (For Agency use only)	APPLICANT INFORMATION (See instructions on reverse)		OMB No. 1205-0371 Expiration Date: April 30, 2008
			Date Received (For Agency Use only)
EMPLOYER INFORMATION
3. Employer Name	4. Employer Address and Telephone		5. Employer Federal ID Number (EIN)
APPLICANT INFORMATION
6. Applicant Name (Last, First, MI)	7. Social Security Number.		8. Have you worked for this employer before? Yes ____ No ____ If YES, enter date: ______________
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 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 during the year before you were hired? Yes ____ No ____
14. Are you a member of a family that received Food Stamps for the 6 months before you were hired? Yes ____ No ____ OR, received Food Stamps for at least a 3-month period during the 5 months before you were hired and 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 any 9 months during the 18 months before you were hired? Yes ___ No___ If NO, 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 Federal or state law limited the maximum time those payments could be made? Yes ___ No ___ If YES, to any question, enter name of primary recipient ________________________________ and 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 _________________________
18. Do you live in an Empowerment Zone or Renewal Community? Yes ____ No ____ OR, in a Rural Renewal County (RRC)? Yes ____ No ____ If YES, enter name of the RRC: _____________________________
19. Did you receive Supplemental Security Income (SSI) benefits for any month ending within 60 days before you were hired? Yes ____ No ____
20. Sources used to document eligibility:
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.
21. Signature		22. Date

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

• W-4

Signed Statement from Authorized Individual w/Specific Description

• Lease Papers

• Voter Registration Card

• Food Stamp Award Letter

• Selective Service

• 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 NOTIC

3 ETA Form 9061 – June 2007