ETA 9063 Employer Certification

E

U.S. Department Labor

Employment and Training Administration

OMB No. 1205-0371

Expiration Date: April 30, 2012

mployer Certification

Work Opportunity Tax Credit

(OPTIONAL FORMAT)

1. NAME/ADDRESS OF CERTIFYING AGENCY AND TELEPHONE NO.	2. CONTROL NO. (For Agency Use Only)				3. DATE COMPLETED:
	4. INITIATING AGENCY CODE (For Agency Use Only)
PART A. EMPLOYER
5. NAME/ADDRESS OF FIRM/TELEPHONE NO.		6. EMPLOYER TAX EIN #:			7. REPRESENTATIVE’S NAME, TITLE & ADDRESS.
PART B. EMPLOYEE
8. SOCIAL SECURITY NO.				9. EMPLOYMENT START DATE (Mo/ Day/Yr.)
10. NAME AND ADDRESS OF EMPLOYEE:			12. VETERAN TARGET GROUP CODES: (“” those that apply) 2Ba. Qualified Veteran receiving SNAP benefits 2Bb. Disabled Veteran 2Bc. Disabled Veteran unemployed for 6 months 2Bd. Veteran unemployed for 4 weeks but less than 6 months 2Be. Veteran unemployed for 6 months Unemployed Veteran Disconnected Youth
11. NON-VETERAN TARGET GROUP CODE AND NAME: ________________________________________
PART C. CERTIFICATION
I HEREBY CERTIFY that the individual named in Part B meets the eligibility criteria of Sec. 51 of the Internal Revenue Code.
13. NAME OF CERTIFYING OFFICER (Print or Type)			14. SIGNATURE. (Certifying Officer)			15. DATE ISSUED:
Comments to Employers: * The VOW to Hire Heroes Act of 2011 (P.L. 112-56) extends and amends the current veteran group, creates two additional categories of unemployed veterans in Section 51 of the Internal Revenue Code, and makes the WOTC available to qualified tax-exempt organizations in Section 52. The VOW Act grants the WOTC to employers that hire certain qualified veterans who begin employment on or after November 22, 2011 and before January 1, 2013. This Act did not extend the non-veteran WOTC categories, which expired on December 31, 2011. For additional information on filing certification requests to the State Workforce Agencies (SWA) and veterans’ eligibility requirements visit WOTC’s national website at www.doleta.gov/wotc to obtain an e-copy of TEGL No. xx-xx, a brochure on “WOTC and Veterans” and a Fact Sheet that provides an overview of the provisions in the VOW Act. Employers are also encouraged to visit IRS’s website at www.irs.gov to obtain e-copies of IRS’s Notice 2012 -13 and the January 2012 IRS Form 8850 and Instructions. EMPLOYERS: Before you can claim the WOTC, your new hire(s) must work the required number of hours to meet the Minimum Employment or Retention Period. Visit IRS’s website at: www.irs.gov for additional information on this and other requirements. Note. More information is available in the instructions for IRS Form 8850 & 5884, Work Opportunity Credit, for tax year 2012.
NOTE: Falsification of data to obtain this Certification is a FEDERAL CRIME in violation of 18 USC 1001. Falsification of work or concealment of information is PUNISHABLE by a fine or imprisonment
Page of 1 of 2 ETA Form 9063 (Rev. February 2012)

INSTRUCTIONS FOR COMPLETING AND ISSUING THE CERTIFICATION FORM (CF) ETA 9063. Documentary evidence of eligibility and/or collateral contacts is required to issue a WOTC Certification. Information on the Certification substantiates the employer is entitled to claim a tax credit against the first-year wages paid to the new hire.

Note: SWAs must inform each employer who receives a WOTC Certification of the required Minimum Employment Period as stated in the "Comment Box" of the Certification. However, enforcement of this requirement is, strictly, an IRS responsibility.

Boxes to be completed on the Certification:

Box 1: Name and Address. Identify the SWA and include the appropriate address and zip code.

Box 2. Control Number. Enter the control number developed by the SWA for its own use.

Box 3. Date Completed. Enter the month, day and year when the form was completed.

Box 4. Initiating Agency Code. Enter agency code developed by SWA for its own use.

Box 5. Name and Address of Firm. Enter employer's name and address including zip code.

Box 6. Employer Tax EIN Number. Enter employer’s taxpayer identification.

Box 7. Representative's Name, Title and Address. Enter the name, title and office location of the individual authorized by the employer to act on the employer’s behalf.

Box 8. Social Security No. Enter the employee's social security number.

Box 9. Employment Start Date. Enter the month, day and year when the employee began to work for the employing firm.

Box 10. Name and Address of Employee. Enter the employee's full name (i.e., last name, first and initial) and address including zip code and telephone number, if available.

Box 11. Targeted Groups. Enter SWA Code and target group name for the certified non-veteran group.

Box 12. Targeted Groups. Indicate, with a check mark ( “ “), which veteran group is being certified.

Box 13. Certifying Official. Key in/print full name and title of authorized certifying official.

Box 14. Signature. Enter authorized, certifying official's signature.

Box 15. Date. Enter month, day and year when the Certification is issued by the certifying official.

Persons are not required to respond to this collection of information unless it displays a currently valid OMB Control Number. Respondent's obligation to reply to these requirements is mandatory under 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 instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information. Send comments regarding the 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 National Programs, Tools, and Technical Assistance, Room C-4510, Washington, D.C. 20210 (Paperwork Reduction Project Control No. 1205-0371).

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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.

Page 2 of 2 ETA Form 9063 (Rev. February 2012)

Page 2 of 2 ETA Form 9063 (Rev. February 2012)