Eta 9062

U.S. Department Labor

Employment and Training Administration

OMB No. 1205-0371

Expiration Date: June 30, 2015

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 or www.doleta.gov/wotc 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. (See IRS Relief Period in TEGL No. XX-XX and IRS Notice xx-xx)
1. INITIATING AGENCY CODE (For Agency Use Only) CODE: ___________		2. CONTROL NO. __________________________________ (For Agency Use Only) Check “” One): ____ Participating Agency ____ SWA
3. FOR EX-FELON TARGET GROUP ONLY a. Conviction Date: _________________ c. Correction’s (Ex-felon’s) ID No.___________ b. Release Date: ___________________						4. DATE COMPLETED (MM/DD/YY) __________________________
5. STATE WORKFORCE AGENCY’s NAME/ADDRESS			6. SIGNATURE (Authorized Official)			7. TELEPHONE No.
PART I. APPLICANT’S INFORMATION AND CONDITIONAL CERTIFICATION (CC):
8. NAME OF APPLICANT (Last, First, Middle)			9. SOCIAL Security No.			10. ENTER TARGET GROUP CODE AND GROUP NAME FOR HIRES OTHER THAN “Veteran”: ________________________________
11. ADDRESS (Street, City, State, Zip Code) &Telephone No.			12. VETERAN TARGET GROUP CODES (Check “” One): 2Ba. 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
				13. APPLICANT SIGNATURE:
NOTE TO EMPLOYER:
14. 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. Applies to Summer Youth group only.			Note. In the event you hire this individual, you should request the certification necessary for you to claim a Work Opportunity Tax Credit (WOTC). Simply complete and sign the Employer Declaration below, submit to the SWA this form together with IRS Form 8850 not later than April 29, 2013 for 1) members of the non-veteran target groups hired on or after January 1, 2012 and on or before March 31, 2013, and for 2) qualified veterans hired on or after January 1, 2013 and on or before March 31, 2013. For all hires after March 30, 2013, employers must meet the 28-day timely filing requirement. 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:
15. NAME OF FIRM AND ADDRESS:	16. POSITON/JOB TITLE:				17. EMPLOYMENT-START DATE:			18. 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 and 52 of the Internal Revenue Code. Employers are advised that such credit will cease immediately upon notification of any subsequent invalidation/revocation.
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.
19. EMPLOYER’S NAME:			20. EMPLOYER’S SIGNATURE:				21. DATE: ((MM/DD/YY)

CONDITIONAL CERTIFICATION (CC) ETA FORM 9062. When a SWA or participating agency (PA) determines that a job-ready applicant is, tentatively, ELIGIBLE as a member of a target group under WOTC, it shall use this required form, without modification, to show that an eligibility pre-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 individual veteran is hired, and provides a means for employers to request a WOTC certification for this person.

INSTRUCTIONS FOR COMPLETING THE “CONDITIONAL CERTIFICATION” FORM. (Boxes 1-8 and 15 are for participating agency (PA) and SWA use only)

Box 1: Initiating Agency Code. If the CC was issued by a Participating Agency (PA), enter its code.. SWAs 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, enter the SWA’s code, if available. Indicate with a check mark “” if initiating agency is a PA or SWA.

Box 2: Control Number. Usually the PA determines the control number (CN). However, SWAs 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.

Box 3: For Ex-Felon Target Group Only. For items a - c, enter the corresponding information. This information will help the SWA or PA in verifying target group eligibility. Note: Box 4 does not apply to veterans hired under the VOW to Hire Heroes Act of 2011.

Box 4: Date Completed. Enter the month, day, year in which the eligibility determination was completed.

Box 5: SWA’s Name and Address. If known, enter or stamp the name and address, including zip code, of the SWA responsible for Certification requests for the employer indicated in Box 156. Leave blank if SWA’s name and address is unknown.

Box 6: Signature. Enter signature of the authorized conditionally-certifying official.

Box 7: Telephone No. Enter corresponding SWA or PA area code, telephone number and extension, if available.

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

Box 8: Name of Individual. Enter the individual’s/applicant’s full name (i.e., last name, first name and middle initial).

Box 19: Social Security Number. Enter the individual’s/applicant’s Social Security Number.

Box 10: Target Group Code. Enter the code or name of the pre-certified non-veteran target group. The non-veteran groups and the Empowerment Zones were retroactively reauthorized through December 31, 2013 by the American Taxpayer Relief Act of 2013 signed into law by President Obama on January 3, 2013. This Act also authorized the continuation of the VOW Act expanded veteran groups and provisions through December 31, 2013.

This box does not apply until Congress reauthorizes the non-veteran groups beyond December 31, 2011.

Box 11: 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 12: Veteran Target Group Code. The 1996 original target group designation for a Qualified Veteran is “B.” To facilitate the identification of the different veteran categories created by the VOW to Hire Heroes Act of 2011 (P.L. 112-56,), ETA is using the same alpha-numeric designations used to collect the number of certifications issued for the amended veteran categories in ETA Form 9058 – Report 1. To ensure a simple, uniform and consistent certification system which can be used by the SWAs nationwide each new veteran category is preceded by “B” and followed by the alpha-numeric code used in ETA Form 9058. Enter a check mark “” in front of the veteran group pre-certified.

Box 13: Signature. Get applicant’s signature. If a minor, parent or guardian must sign here.

Box 14: CC Validity Period. (This box is to be completed by the SWA or PA). Enter the month/day/year when the CC expires.

This box does not apply to veterans pre-certified under the VOW to Hire Heroes Act of 2011.

Box 15: Name of Firm. Enter full name of the employing firm (the firm where the employee will actually work).

Box 16: Position/Job Title. Enter the position or job title the employee will hold.

Box 17: Employment-Start Date. Enter the date the employee began or will begin work for the employing firm.

Box 18: Starting Wage. Enter the wage or salary which the employee will be paid. If not known, enter an estimated wage.

Box 19: Employer’s Name. Enter your name as the hiring employer.

Box 20: Employer’s Signature. Affix your electronic or ink signature here.

Box 21: 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, Employment and Training Administration, Division of National Programs, Tools, and Technical Assistance, 200 Constitution Ave., NW, Room C-4510, 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. March 2013)