Form ETA-9057 Conditional Certifications Issued

Conditional Certifications Issued U.S Department of Labor

Work Opportunity Tax Credit Program Employment and Training Administration

Summary Worksheet (For SWA Internal Use Only)

State:	Quarter Ending:	Control No. (For Agency Use Only)	OMB No. 1205-0371 Expiration Date:
I. By Issuing Agency	No. of Conditional Certifications Issued	II. By WOTC Target Group	No. of Conditional Certifications Issued
	WOTC		WOTC
1.Employment Service		13. IV-A Recipient
2. One Stop Career Center		14. Veteran
		14a. Disabled Veteran
3. WIA LWIAs, Partner Agencies, and Training Providers		15. Ex-Felon
4. Voc. Rehab. Agencies		16. Designated Community Resident
5. Veteran Affairs Offices		17. Vocational Rehabilitation Referral
6. Welfare Offices		17.a. Ticket Holders
7. Social Security District Offices		18. Summer Youth
8. All Other Pas		19. Food Stamp Recipient
9. Employment Networks		20. SSI Recipient
		21. Long-Term Family Assistance Recipient
10. TOTAL (for quarter)		22. TOTAL (for quarter)
11. TOTAL (year-to-date)		23. TOTAL (year-to-date)
24. Name/Title of Responsible Official:	25. Signature:		26. Date:

Page 1 of 2 ETA Form 9057 (Rev. June-07)

Instructions for Preparing ETA Form 9057 – Summary Worksheet (For SWA Internal Use Only)

ETA Form 9057 - Conditional Certifications Summary Worksheet for the Consolidated Work Opportunity Tax Credit and Participating Agencies (PA) is designed to summarize the number of Conditional Certifications (ETA Form 9062s) issued during each quarter by the SWAs/DLAs and the PAs. The summary worksheet should be prepared using data collected from ETA Form 9062.

This summary worksheet helps the SWAs in collecting quarterly data on conditional certifications for the

WOTC.

The Summary Worksheet is divided into two sections. The first section, entitled "I. By Issuing Agency” collects the number of WOTC conditional certifications (CCs) issued by the SWAs/DLAs and all Participating Agencies (boxes 1-10).

Where no CCs have been issued, please enter “0"

The second section, entitled "II. By WOTC Target Group,” collects the number of WOTC CCs issued by the different nine target groups (boxes 13-21).

Where no CCs have been issued, please enter "0."

The quarterly and year-to-date (cumulative) totals in Section I (boxes 11-12, respectively) should equal the quarterly and year-to-date (cumulative) totals in Section II (boxes 22-23, respectively).

Finally, the WOTC responsible official should enter/type his/her name in box 24 and affix his/her signature in box 25. Then enter the date the summary worksheet was prepared in box 26.

NOTE: This form no longer collects information on conditional certifications by type, i.e., by whether they are "original" or "revalidated" (Box 3 of ETA 9062). Therefore, counts of CCs in boxes 1-10 and 13-21 should not distinguish between original and revalidated CCs. For example, if in the first quarter of Fiscal Year 2006, an agency issued 70 original and 30 revalidated CCs, that agency issued 100 CCs. Note also that this form no longer reports invalidations of conditional certifications.

Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Respondents’ obligation to reply to

these reporting requirements is required to obtain or maintain benefits (P.L. 104-188). Public reporting burden for this collection of information is estimated to average1 hour 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 or any other aspect of this collection of information, including suggestions for reducing this burden to the U.S. Department of Labor, Division of Adult Services, Room C-4514, Washington, D.C. 20210 (Paperwork Reduction Project 1205-0371),

Page 2 of 2 ETA Form 9057 (Rev. Jan. 2007)