ETA-9154 Youth Self Attestation

OMB No. 1205-0371

Expiration Date: 11/30/2011

STATE NAME AND ADDRESS

YOUTH SELF-ATTESTATION FORM

Work Opportunity Tax Credit Program

Applicant Name: ___________________________________________________________

Social Security Number: _________________ Date of Birth: ______________________

(If under age 25)

Employer Name: ___________________________________________________________

Employer’s Address: ________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Employer’s Telephone Number: ______________________________________________

Please check the statement that applies to you, sign and date this form where indicated below.

 I do not have a High-School diploma or GED certificate. If I attended High School or a GED program in the last 6 months, it was for no more that an average of 10 hours per week, not counting periods during which the school was closed for a scheduled vacation.

 I have a High-School diploma or GED certificate awarded more than 6 months ago and I have not attended or been admitted to a technical or post-secondary school.

 I have not held a job (other than occasionally) since receiving my High-School diploma or GED certificate.

Under penalties of perjury, I declare that this information is true and correct to the best of my knowledge.

I authorize any organization, state or federal government agency (including state Unemployment

Insurance agencies) to such verification or information as may be needed to determine WOTC eligibility

to my employer, employer representative, or the State Workforce Agencies.

Signature: _______________________________________ Date: __________________________

ETA-9154 Dec 2009