updated Form ETA-9061 with responses to OMB

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

Work Opportunity Tax Credit Employment and Training Administration

Control No. (For Agency use only)	APPLICANT INFORMATION (See instructions on reverse)	OMB No. 1205-0371 Expiration Date: November 30, 2011
		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 last date of employment: ____________
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 SNAP (Food Stamps) benefits the 15 months for at least 3 months during 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 the 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 Supplemental Nutritional Assistance Program (SNAP) (Food Stamps) benefits for the 6 months before you were hired? Yes ___ No___ OR, received SNAP benefits for at least a 3-month period within the last 5 months But you 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 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 a Federal or state law limited the maximum time those payments could be made? Yes___No___ If NO, are you a member of a family that received TANF assistance for any 9 months during the 18 month period before you were hired? Yes___No___ If YES, to any question, enter name of primary recipient ________________________ and The 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 _________________. Was this a Federal ____ or a State conviction_____? (Check one)
18. Do you live, and plan to continue living, 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. Are you an unemployed veteran who served on active duty (other than active duty for training) in the Armed Forces of the United States for a period of more than 180 days? Yes___ No___ OR were you discharged or released from active duty in the Armed Forces for a service-connected disability? Yes___ No___ If YES, where you discharged or released from active duty in the Armed forces at any time during the 5-year period ending on the hiring date? Yes___ No___ If YES, did you receive unemployment compensation for not less than four weeks during the one-year period ending on your hiring date? Yes___ No___
21. Are you at least age 16 but under age 25? Yes___ No___ If YES, did you not regularly attend any secondary, technical, or post-secondary school during the 6-month period before your hiring date? Yes___ No___ If YES were you not regularly employed during that 6-month period? Yes___ No___ If YES, were you not employable because you lacked basic skills? Yes___ No___
22. Sources used to document eligibility: (Employers/Consultants: List all documentation provided or forthcoming. SWAs: List all documentation used in determining target group eligibility and enter your initials and date when determination was made.)
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.
23(a). Signature: (See instructions infor Box 23b for who signs this signature block)	23. (b) Indicate with a  who signed the form:  Employer,  Consultant,  SWA,  Participating Agency,  Applicant, or  Parent/Guardian (if applicant is a minor)	24. 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, on behalf of the applicant, by: 1) the employer or employer representative, the SWA, a participating agency, or by 2) the applicant directly (if a minor, the parent or guardian must sign the form) and signed by the individual completing the form. This form is required to be used, without modification, by all employers (or their representatives) seeking WOTC certification.

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 Yes, enter the last date or approximate last date of employment. This information will help the “48-hour” reviewer to, early in the verification process, eliminate requests for former employees and to issue denials to these type of requests, or certifications in the case of “qualifying rehires” during valid “breaks in employment” (see pages III-12 and III-13, Nov. 2002, Third Ed., ETA Handbook 408) during the first year of employment.

Boxes 12-21. Applicant Characteristics. Read questions carefully, answer each question, and provide additional information where requested.

Box 22 Sources to Document Eligibility. The applicant or employer is requested to 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. Employers: 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. SWAs will use this box to document the sources used when verifying target group eligibility, followed by their initials and the date the determination was completed.

E xamples of Documentary Evidence and Collateral Contacts. Employers/Consultants: You may check with your SWA to find out what other sources you can use to prove target group eligibility. (You are encouraged to provide copies of documentation or names of collateral contacts for each question for which you answered YES.)

QUESTION 12³

• Birth Certificate

• Driver’s License

• School I.D. Card¹

• Work Permit¹

• Federal/State/Local Gov’t I.D.¹

• Copy of Hospital Record of Birth

QUESTION 13

• DD-214 or Discharge Papers

• Reserve Unit Contacts

• FL 21-802 (Issued ONLY by DVA. Certifies a Veteran with a service connected disability)

• UI claims records (for unemployed status)

QUESTIONS 14 & 16

• TANF/SNAP (Food Stamp) Benefit

History

• Signed Statement from Authorized Individual with Specific

Description of the Months Benefits Were Received

• Case Number Identifier

QUESTION 15

• Vocational Rehabilitation Agency Contact

• Veterans Administration

• Signed Statement from Authorized Individual

With Specific Description of Months Benefits Received

• For SWAs: To determine Ticket Holder (TH) eligibility,

Fax page 1 of Form 8850 to MAXIMUS to 703-683-1051 to verify if applicant:

1) is a TH, and 2) has an Individual Work Plan 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

• Lease Papers or Landlord’s Statement

• School¹ or Library Card²

• Voter Registration Card

• SNAP (Food Stamp) Award Letter

• Selective Service Registration Card

• Social Security Letter

• To determine if a Designated Community Resident lives in

a RRC, visit the site: www.usps.com. Click on Find Zip Code; Enter & Submit Address/Zip Code; Click on

Mailing Industry Information; Download and Print the

Information, then compare the county of the address to

the list in the June 2007 Instructions to IRS 8850.

QUESTION 19

• SSI Record or Authorization

• SSI Contact

• Evidence of SSI Benefits

Notes. 1. Where a Federal/State/Local Gov’t., School I.D. Card, or Work Permit

does not contain age or birth date, another valid document must be obtained to

verify an individual’s age.

2. Where a Library Card does not contain the holder’s address another document,

issued in the jurisdiction where the EZ/RC or RR County is located, must be

obtained showing the holder’s address.

3. ESPL No. 05-98, dated 3/18/98, 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.

QUESTION 20

• DD-214

• FL 21-802 (Issued ONLY by DVA. Certifies a Veteran with a service connected disability)

• Discharge Papers

• UI claims records (for unemployed status)

QUESTION 21

To determine age:

• Birth Certificate

• Driver’s License

• Work Permit

• Copy of Hospital Record of Birth

• School I.D. Card/School Records

• Federal/State/Local Government I.D.

To determine youth has not regularly attended any secondary, technical or post secondary school:

• Self-Attestation

• Signed letter from parent/guardian (if minor)

To determine unemployed status during the 6-month period before hiring date:

• UI Wage Records

To determine unemployable status due to lack of basic skills:

• Self-Attestation that he/she has a High School (HS) or GED Certificate that was awarded no les than

6 months preceding his or her hiring date and has not held a job other than occasionally or been admitted to a technical school

or post-secondary school since receiving the certificate.

Box 23. Signature. The person who completes the form signs the signature block. Options: (a) Employer or Authorized Representative, (b) SWA staff,

(c) Participating Agency staff, or (d) Applicant (If applicant is a minor, the parent or guardian must sign).

Box 24: 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 Services, Room S-4209, Washington, D.C. 20210 (Paperwork Reduction Project

Control No. 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.

5 ETA Form 9061 (August 2009)