OMB Control No. 1205-0371
Expiration Date: November 30, 2011
YOUTH SELF-ATTESTATION FORM
Work Opportunity Tax Credit Program
Instructions: This Self-Attestation Form (SAF) is to be completed, signed and dated by the new hire on or before the day the job offer is made. The employer or consultant is to submit the SAF to the state workforce agency together with IRS Form 8850 within 28 calendar days from the employment start date of the new hire.
New Hire Name: ___________________________________________________________
Social Security Number: _________________ Date of Birth:_______________________
(If under age 25)
Employer Name: ___________________________________________________________
Employer Federal ID (EIN) Number: ___________________________________________
Please check all the statements that apply to you. Sign and date this form where indicated below.
In the past 6 months, I have not attended a secondary, technical or postsecondary school for more than an average of 10 hours per week, not counting periods during which the school is closed for scheduled vacations.
I do not have a High School Diploma or GED certificate.
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 also 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.
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New Hire’s Signature: _______________________________________________Date_________
Public Burden Statement:
Persons are not required to respond to this collection of information unless it displays a currently valid OM B control number. Respondents' obligation to complete this form is required to obtain or retain benefits (P.L. 111-5). Public reporting burden is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of Information. Send comments regarding this burden estimate to the U.S. Department of Labor, Division of Adult Services, Room S-4209, Washington, D.C. 20210 (Paperwork Reduction Project 1205-0371).
ETA Form 9154 (February 2010)
| File Type | application/msword |
| File Title | YOUTH SELF-ATTESTATION FORM |
| File Modified | 2010-02-03 |
| File Created | 2010-02-02 |