Work Opportunity Tax Credit

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form ETA 9058 Certification Workload and Characteristics of Certified Individuals	Form and Instruction	Modified	Available
Form ETA 9062 Conditional Certification	Form and Instruction	Modified	Available
Form ETA 9061 Individual Characteristics Form	Form and Instruction	Modified	Available
Form ETA 9063 Employer Certification	Form and Instruction	Modified	Available
Form ETA 9065 Agency Declaration of Verification Results	Form and Instruction	Modified	Available
Form ETA 9175 LONG-TERM UNEMPLOYMENT RECIPIENT SELF-ATTESTATION FORM	Form	Modified	Available
Form ETA 9062 Conditional Certification	Form and Instruction	Modified	Available
Form ETA 9061 Individual Characteristics Form	Form and Instruction	Modified	Available
Form ETA 9061 Spanish V Individual Characteristics Form, Spanish Version	Form	Modified	Available
BILLS-114hr2029enr see p815.pdf	Supplementary Document	Uploaded 2016-04-20	Available
1205-0371 Supporting Statement_FINAL 11.25.16.docx	Supporting Statement A	Uploaded 2016-11-25	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
43791	Work Opportunity Tax Credit (WOTC)	Form and Instruction	Modified	Certification Workload and Characteristics of Certified Individuals
43791	Work Opportunity Tax Credit (WOTC)	Form and Instruction	Modified	Conditional Certification
43791	Work Opportunity Tax Credit (WOTC)	Form and Instruction	Modified	Individual Characteristics Form
43791	Work Opportunity Tax Credit (WOTC)	Form and Instruction	Modified	Employer Certification
43791	Work Opportunity Tax Credit (WOTC)	Form and Instruction	Modified	Agency Declaration of Verification Results
221431	Qualified Long-term Unemployment Recipient (LTUR)	Form	Modified	LONG-TERM UNEMPLOYMENT RECIPIENT SELF-ATTESTATION FORM
184551	Individual Characteristics	Form and Instruction	Modified	Conditional Certification
184551	Individual Characteristics	Form and Instruction	Modified	Individual Characteristics Form
184551	Individual Characteristics	Form	Modified	Individual Characteristics Form, Spanish Version

ICR Details

OMB Control No: 1205-0371	ICR Reference No: 201611-1205-003
Status: Historical Active	Previous ICR Reference No: 201604-1205-005
Agency/Subagency: DOL/ETA	Agency Tracking No: 012-05-01-02-02-2025-00.
Title: Work Opportunity Tax Credit
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/23/2017
Retrieve Notice of Action (NOA)	Date Received in OIRA: 11/30/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2020	36 Months From Approved	01/31/2017
Responses	5,840,620	0	5,840,620
Time Burden (Hours)	1,960,777	0	1,960,774
Cost Burden (Dollars)	0	0	0

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Abstract: The Work Opportunity Tax Credit (WOTC) is a Federal tax credit available to employers for hiring individuals from certain target groups who have consistently faced significant barrier to employment. This submission includes seven WOTC program forms as follows: • ETA Form 9175, Revised November 2016 – Self-Attestation Form (SAF) for the Long-Term Unemployment Recipient • ETA Form 9058 - Report 1, Revised April 2016 - Certification Workload and Characteristics of Certified Individuals • ETA Form 9061, Revised November 2016 - Individual Characteristics Form • ETA Form Spanish 9061, Revised November 2016 - Individual Characteristics Form • ETA Form 9062, Revised April 2016 - Conditional Certification • ETA Form 9063, Revised April 2016 - Employer Certification • ETA Form 9065, Revised April 2016 - Agency Declaration of Verification Results Worksheet

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Authorizing Statute(s): PL: Pub.L. 101 - 508 11405(c) Name of Law: Omnibus Budget Reconciliation Act of 1989
   PL: Pub.L. 97 - 34 261(f)(2) Name of Law: Economic Recovery Act of 1981
   PL: Pub.L. 97 - 248 233(e) Name of Law: Tax Equity and Fiscal Responsibility Act of 1982
   PL: Pub.L. 98 - 369 1041(b) Name of Law: Tax Equity and Fiscal Responsibility Act of 1982
   PL: Pub.L. 99 - 514 1701(d) Name of Law: Tax Equity and Fiscal Responsibility Act of 1982
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 51497	08/04/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 86341	11/30/2016
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Individual Characteristics	ETA 9061 Spanish Version, ETA 9061, ETA 9062	Individual Characteristics Form, Spanish Version ,   Individual Characteristics Form ,   Conditional Certification
Qualified Long-term Unemployment Recipient (LTUR)	ETA 9175	LONG-TERM UNEMPLOYMENT RECIPIENT SELF-ATTESTATION FORM
Work Opportunity Tax Credit (WOTC)	ETA 9058, ETA 9065, ETA 9063, ETA 9062, ETA 9061	Agency Declaration of Verification Results ,   Employer Certification ,   Individual Characteristics Form ,   Conditional Certification ,   Certification Workload and Characteristics of Certified Individuals

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	5,840,620	5,840,620	0	0	0	0
Annual Time Burden (Hours)	1,960,777	1,960,774	0	0	3	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $11,480

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 11/30/2016

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