Form ETA-9062 Conditional Certification

U.S. Department Labor

Employment and Training Administration

OMB No. 1205-0371

Expiration Date: December 31, 2011

Conditional Certification

Work Opportunity Tax Credit

EMPLOYERS! This form must be accompanied by IRS Form 8850. If you do not have IRS Form 8850, call 202-693-2786 for a copy or download it from www.irs.gov Be sure to complete Part II of this form and IRS 8850, sign and date both forms BEFORE sending them to the State Workforce Agency (SWA) within 28 days after the new hire’s employment-start date.
1. INITIATING AGENCY CODE (For Agency Use Only) CODE: ___________		2. CONTROL NO. (For Agency Use Only) “” One) _______________ ____ Participating Agency ____ SWA/DLA				3. TYPE OF CONDITIONAL CERTICATION a.  Original (For Summer Youth ONLY, “” One) a.  Original b.  Revalidation
4. FOR EX-FELON TARGET GROUP ONLY. a. Conviction Date: _________________ c. Correction’s ID No.___________ b. Release Date: ___________________						5. DATE COMPLETED (MM/DD/YY) __________________________
6. STATE WORKFORCE AGENCY’s NAME/ADDRESS			7. SIGNATURE (Authorized Official)			8. TELEPHONE No.
PART I. APPLICANT’S INFORMATION AND CONDITIONAL CERTIFICATION (CC):
9. NAME OF APPLICANT (Last, First, Middle)			10. SOCIAL Security No.			11. TARGET GROUP CODE ( “” if Disabled Veteran meets the requirements below) Disabled Veteran entitled to:  Compensation for a service-connected disability & during the past year was released/discharged from active duty, or  unemployed for a period totaling 6 months.
12. ADDRESS (Street, City, State, Zip Code) &Telephone No.			13a. TARGET GROUP CODE (“” One)  Ticket Holder (TH) with IWP from an Employment Network, Summer Youth (SY), Long-Term Family Assistance Recipient (LTFAR), or Designated Community Resident (DCR). If DCR, enter name of RRC in the blank: ___________________________________ Name of RR County Enter Code if not a TH, SY, LTFAR, or DCR _______________
13b. TARGET GROUP (Cont):  Unemployed Veteran  Disconnected Youth				14. APPLICANT SIGNATURE:
NOTE TO EMPLOYER:
1 5. The above named individual may be eligible for certification under the Work Opportunity Tax Credit. If individual is not employed before the date in the box below (Mo., Day, Yr.), this eligibility determination is subject to review.			In the event you hire this person, you should request the certification necessary for you to claim a Work Opportunity Tax Credit (WOTC). Simply, complete and sign the Employer Declaration below, mail to the SWA or Designated Local Agency together with IRS Form 8850, not later than the 28th day after the applicant starts work. The WOTC Employer Certification will be sent to you, if all statutory requirements have been met.
PART II. EMPLOYER DECLARATION: I, hereby, declare that the above named person is or will be employed by:
16. NAME OF FIRM AND ADDRESS:	17. POSITON/JOB TITLE:				18. EMPLOYMENT-START DATE:			19. STARTING WAGE: $ ___________ per hr.
ATTN SWA: Please send a WOTC Certification for this employee. The pre-certification is for the purpose of requesting Certification to obtain the WOTC under Sec. 51 of the Internal Revenue Code. Employers are advised that such credit will cease immediately upon notification of any subsequent invalidation/revocation. Employers are further advised that if the certification herein requested is for a member of the SUMMER YOUTH target group, the tax credit for which he/she may be eligible is subject to the limits described at Sec. 51 (d)(7) of the Internal Revenue Code.
NOTE: Falsification of data on this form is a FEDERAL CRIME in violation of 18 USC 1001. Falsification of work or concealment of information is PUNISHABLE by a fine or imprisonment.
20. EMPLOYER’S NAME:			21. EMPLOYER’S SIGNATURE:				22. DATE: ((MM/DD/YY)

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CONDITIONAL CERTIFICATION (CC) ETA FORM 9062. When a SWA/DLA or Participating Agency (PA) determines that a job-ready applicant is, tentatively, ELIGIBLE as a member of a target group under the consolidated WOTC, it shall use this required form, without modification, to show that an eligibility determination was made for this person. Note. The CC serves as an official record of the pre-certification, alerts prospective employers to the availability of the tax credit if this person is hired, and provides a means for employers to request a WOTC certification for this person.

INSTRUCTIONS FOR COMPLETING THE “CONDITIONAL CERTIFICATION” FORM. (Boxes 1-15 are for Participating Agency (PA) and SWA/DLA use only)

Box 1: Initiating Agency Code. If the CC was issued by a Participating Agency, enter its code. SWAs/DLAs assign codes to designate each PA and indicate the initiating source for the eligibility determination process. If the eligibility determination was performed by the SWA/DLA, enter the SWA/DLA code, if available. Indicate with a check mark “” if initiating agency is a PA or SWA/DLA.

Box 2: Control Number. Usually the PA determines the control number (CN). However, SWAs/DLAs may, for internal control purposes, develop their own CN system. It may be a case number or some other appropriate designation (e.g., alpha-numeric designation), which permits easy filing, certification and retrieval of forms. Enter corresponding CN and indicate with a check mark “” whether the source is a PA or a SWA/DLA.

Box 3: Type of Conditional Certification. This system distinguishes between “Original,” if the individual is being processed for the first time, or “Revalidation,” if the eligibility process was performed within the previous 12-month period, (e.g. , 45 days for the Summer Youth target group only). Otherwise, the Conditional Certification is counted as “Original.” Indicate with a check mark “” whether the eligibility determination is “Original” or “Revalidation.”

Box 4: For Ex-Felon Target Group Only. For items a - c, enter the corresponding information. This information will help you in verifying target group eligibility.

Box 5: Date Completed. Enter the month, day, year in which the eligibility determination was completed.

Box 6: SWA/DLA’s Name and Address. (If known, enter or stamp the name and address, including zip code, of the SWA/DLA responsible for Certification requests for the employer indicated in Box 16. Leave blank if SWA/DLA’s name and address is unknown.

Box 7: Signature. Enter signature of the authorized conditionally-certifying official.

Box 8: Telephone No. Enter corresponding SWA/DLA or PA area code, telephone number and extension, if available.

PART I. APPLICANT’S INFORMATION AND CONDITIONAL CERTIFICATION (CC):

Box 9: Name of Individual. Enter the individual’s/applicant’s full name (i.e., last name, first name and middle initial).

Box 10: Social Security Number. Enter the individual’s/applicant’s Social Security Number.

Box 11: Target Group Code. Enter a check mark “” to indicate if individual is being pre-certified as a Disabled Veteran meeting the requirements introduced by P.L. 110-28.

Box 12: Address/Telephone No. Enter the individual’s/applicant’s home address, including apartment number and zip code. After address, enter individual’s telephone number, including area code.

Box 13a: Target Group Code. Enter a check mark “” to indicate if “Summer Youth, “Ticket Holder (TH)” with an IWP from an Employment Network (EN), Long-term Family Assistance Recipient (LTFAR), or Designated Community Resident (DCR). If a DCR living in a RRC, enter name of county on the blank space. If different from Summer Youth, Ticket Holder, LTFAR, or DCR, enter code for specific WOTC target group based on applicant’s information and available documentation.

Box 13b: Target Group Code (Continued). Enter a check mark “” to indicate if individual is being pre-certified as “Unemployed Veteran” or “Disconnected Youth” meeting the requirements introduced by the Recovery Act of 2009, P.L. 111-5.

Box 14: Signature. Get applicant’s signature. If a minor, parent or guardian must sign here.

Box 15: CC Validity Period. (This box is to be completed by the SWA/DLA or PA). Enter the month/day/year when the CC expires

(e.g., 45 days for Summer Youth)

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PART II. EMPLOYER DECLARATION:

Box 16: Name of Firm. Enter full name of the employing firm (the firm where the employee will actually work).

Box 17: Position/Job Title. Enter the position or job title the employee will hold.

Box 18: Employment-Start Date. Enter the date the employee began or will begin work for the employing firm.

Box 19: Starting Wage. Enter the wage or salary which the employee will be paid. If not known, enter an estimated wage.

Box 20: Employer’s Name and Signature. Enter your name as the hiring employer.

Box 21: Employer’s Signature. Sign this form.

Box 22: Date. Enter month, day and year when you signed this form.

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 questions is required for obtaining the tax credit per P.L. 104-188. Public reporting burden for this collection of information is estimated to average .33 minutes per response, including the time for reading instruction, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden to the U.S. Department of Labor, Division of Adult Services, Room S-4209, Washington, D.C. 20210 (Paperwork Reduction Project 1205-0371)

Privacy Act Statement:  The Internal Revenue Code of 1986, Section 51, as amended and its enacting legislation, P.L. 104-188, specify that the State Workforce Agencies are the "designated" agencies responsible for administering the WOTC certification procedures of this program. The information you have provided completing this form will be disclosed by your employer to the State Workforce Agency.  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.

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ETA Form 9062 (Rev. Aug. 2009) Previous versions usable.