WOTC Self-Attestation Form (ETA-9154)

Work Opportunity Tax Credit and Welfare-to-Work Tax Credit

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1205-0371 can be found here:

Documents and Forms

Document Name Document Type
Form ETA 9154 WOTC Self-Attestation Form (ETA-9154) Form
ETA 9154 Youth Self Attestation Youth attachment I.doc Form
ETA 9154, Spanish Youth Self Attestation, Spanish Version Youth Attachment II.doc Form
TEGL 5-19-10.doc with highlights.doc TEGL Change 3 Guidance IC Document

Information Collection (IC) Details

IC Title:	WOTC Self-Attestation Form (ETA-9154)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	ETA 9154	Youth Self Attestation	Youth attachment I.doc		Yes	No	Printable Only
Form	ETA 9154, Spanish Version	Youth Self Attestation, Spanish Version	Youth Attachment II.doc		Yes	No	Printable Only

Line of Business: Workforce Management

Subfunction: Training and Employment

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 53	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 90 %

	Requested	Previously Approved
Annual Number of Responses for this IC	106,000	106,000
Annual IC Time Burden (Hours)	34,980	34,980
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
TEGL Change 3 Guidance	TEGL 5-19-10.doc with highlights.doc	05/20/2010

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.