Information Collection

Qualified Long-term Unemployment Recipient (LTUR)

IC 221431 under ICR 201604-1205-005 · 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⚠️ Notice: This information collection may be referencing outdated material.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 9175 Qualified Long-term Unemployment Recipient (LTUR)	Form
ETA 9175 LONG-TERM UNEMPLOYMENT RECIPIENT SELF-ATTESTATION FORM WOTC SAF for Long-Term Unemployment Recipient ETA Form 9175_FINAL 5.17.16.doc	Form

IC Title:

Qualified Long-term Unemployment Recipient (LTUR)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	ETA 9175	LONG-TERM UNEMPLOYMENT RECIPIENT SELF-ATTESTATION FORM	WOTC SAF for Long-Term Unemployment Recipient ETA Form 9175_FINAL 5.17.16.doc		Yes	Yes	Fillable Fileable Signable

Line of Business: Workforce Management

Subfunction: Training and Employment

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 95,741

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Farms, Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	95,741	95,741
Annual IC Time Burden (Hours)	16,276	16,276
Annual IC Cost Burden (Dollars)	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.