Information Collection

Work Opportunity Tax Credit (WOTC) and Welfare-to-Work (WtW) Tax Credit

IC 43791 under ICR 201201-1205-001 · OMB 1205-0371.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form ETA 9065 Work Opportunity Tax Credit (WOTC) and Welfare-to-Work (WtW) Tax Credit	Form and Instruction
ETA 9065 Agency Declaration of Verificatino Results ETA Form 9065 ADVR (3-5-2012).doc	Form and Instruction
ETA 9061 Individual Characteristics Form ETA Form 9061 (3-5-2012).doc	Form and Instruction
ETA 9063 Employer Certification ETA Form 9063 Certification (3-5-2012).doc	Form and Instruction
ETA 9062 Conditional Certification ETA Form 9062 Conditional Certification (w-Privacy Act Lang & LOGO CO 8-12-2011).doc	Form and Instruction
ETA 9058 Certification Workload ETA Form 9058 - (3-5-2012).doc	Form and Instruction

IC Title:

Work Opportunity Tax Credit (WOTC) and Welfare-to-Work (WtW) Tax Credit

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	ETA 9065	Agency Declaration of Verificatino Results	ETA Form 9065 ADVR (3-5-2012).doc	Yes	Yes	Paper Only
Form and Instruction	ETA 9061	Individual Characteristics Form	ETA Form 9061 (3-5-2012).doc	Yes	Yes	Fillable Fileable Signable
Form and Instruction	ETA 9063	Employer Certification	ETA Form 9063 Certification (3-5-2012).doc	Yes	Yes	Fillable Fileable Signable
Form and Instruction	ETA 9058	Certification Workload	ETA Form 9058 - (3-5-2012).doc	Yes	Yes	Fillable Fileable Signable
Form and Instruction	ETA 9062	Conditional Certification	ETA Form 9062 Conditional Certification (w-Privacy Act Lang & LOGO CO 8-12-2011).doc	Yes	Yes	Fillable Fileable Signable

Line of Business: Workforce Management

Subfunction: Training and Employment

Privacy Act System of Records

Title: DOL/ETA-15

FR Citation: 75 FR 6884

Number of Respondents: 52

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,430,624	0	-404	1,431,028
Annual IC Time Burden (Hours)	520,745	-5	-875	521,625
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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