Form ETA 9065 ETA 9065 Agency Declaration of Verification Results

Work Opportunity Tax Credit U.S. Department of Labor

(For SWAs’ Internal Use Only) Employment and Training Administration

			OMB Control No. 1205-0371 Expiration Date: November 30, 2016
1. NAME OF INDIVIDUAL	Agency Declaration of Verification Results (ADVR) Worksheet		2. SOCIAL SECURITY NO.
3. EMPLOYER’S NAME, TELEPHONE NO., AND ADDRESS:
THE SECTION BELOW IS TO BE COMPLETED BY THE SWA/DLA CERTIFYING AGENCY ONLY.
4. CERTIFYING AGENCY: (Check one) CC Issued By: ___ Participating Agency or ___ SWA		5. DATE CERTIFIED:
6. SOURCES USED TO DOCUMENT ELIGIBILITY:
7. AUDIT SAMPLE RESULTS (Complete ONLY if selected as part of RANDOM SAMPLE in a quarterly audit) a.  I have reviewed/contacted the source(s) indicated in box 6 above and have confirmed that the certified individual is ELIGIBLE. b.  I have reviewed/contacted the source(s) indicated in box 6 above and have confirmed that the certified individual is INELIGIBLE for the following reason(s): c.  I have not been able to establish that the certified individual is INELIGIBLE because:
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.
8. NAME AND TITLE OF REVIEWER (Type or Print):		9. SIGNATURE (Certifying Officer)		10. DATE:
Persons are not required to respond to this collection of information unless it displays a valid OMB Control Number. Respondent's obligation to reply to these requirements is mandatory by P.L. 104-188. Public reporting burden for this collection of information is estimated to average 1 hour 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 US. Department of Labor, Division of National Programs, Tools and Technical Assistance, 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.
Page of 1 of 2 ETA Form 9065 (Rev. April 2016)

Instructions for Completing the Agency Declaration of Verification Results (ADVR) Worksheet, ETA FORM 9065.

Background: The Omnibus Budget Reconciliation Act of 1990, P. L. 101-508, § 11405(c), extended indefinitely the $5 million set-aside (cited below) for testing whether individuals certified as members of WOTC targeted groups are eligible for certification (including the use of statistical sampling techniques). As long as there is a WOTC appropriation, this requirement continues in force. These provisions apply in full force to the certification process under the WOTC Program. Section 261(f)(2) of the Economic Recovery Tax act of 1981 (P .L. 97-34), as amended, states that:

“(A) $5,000,000, shall be used to test whether individuals certified as members of targeted groups under

section 51of such Code [Internal Revenue] are eligible for such certification (including the use of

statistical sampling techniques), and (B) the remainder shall be distributed under performance standards

prescribed by the Secretary of Labor.”

Note. Verification activities require testing the validity of all Certifications issued by the SWAs/DLAs, including the Conditional Certifications issued by Participating Agencies (PAs) and other documentation, which result in Certifications. Quality reviews and audits are both parts of the certification process. A General Accounting Office (GAO) report recommended that verification activities be done by an employee "other than the person who originally processed..." the Individual Characteristics [ETA Form 9061] or the Conditional Certification [ETA Form 9062] forms.

DEFINITIONS:

1. Quality Reviews - the reviews conducted at specific points in the eligibility determination/certification process of forms and other documentation including the Certification to ensure that the required information is complete and accurately recorded.

2. Audit - the post-issuance examination of a “random sample” (see p. VIII-23 of Chapter VII. of the Nov. 2002, 3^rd., Edition of ETA Handbook 408 for a chart of “Sample Sizes” and related instructions) of Certifications issued and supporting documentation used to verify the validity of the Certifications issued. These activities support the integrity of the processing system and the program.

INSTRUCTIONS FOR COMPLETING THE AGENCY DECLARATION OF VERIFICATION RESULTS (ADVR) FORM.

Box 1. Name of Individual. Enter the full name (last, first and middle initial) of the certified target group member/employee.

Box 2. Social Security No. Enter the employee's social security number.

Box 3. Employer Name, Telephone No., & Address. Enter employer's name and address including zip code and telephone number.

Box 4. Certifying Agency. Enter name of SWA/DLA issuing the Certification. Indicate with a check mark “” whether the CC was issued by a Participating Agency or a SWA.

Box 5. Date Certified. Enter month, day and year when the Certification was issued.

Box 6. Documentary Sources. List and/or describe the documentary evidence or sources of collateral contacts that are attached to the Certification request (IRS 8850) and/or Individual Characteristics Form.

Box7. Audit Sample Results. Indicate with a check mark “” if individual is "eligible," "ineligible” or “eligibility cannot be determined” and follow the instructions below.

1. If review of documentation reveals that the certified individual is eligible, enter a check mark“.”

2. If review of documentation reveals that the certified individual is ineligible, explain why, and for Conditional Certifications (CCs) prepare and send the following notices:

Notification of Invalidation (NOI) - to the applicant, the SWA/DLA, PA staff; and employer/consultant. The NOI notifies the Participating Agency (PA), applicant, and the employer/consultant to whom applicant was referred to that the Conditional Certification (CC) (ETA Form 9062) is INVALID because of missing or incorrect information/items.

Notice of Revocation (NOR) - prepare and send to employer/consultant a newly updated version of a NOR and send a copy to the Regional and National offices, the applicant and the Participating Agency (if involved) and FAX a copy of the Notice of Revocation to the IRS to following new Fax Number:

Internal Revenue Service

SB/SE Campus Compliance Services

Fax: 1-855-242-6540 

Note to SWA Coordinator/Reviewer. If review of documentation reveals that the SWA/DLA has not been able to establish eligibility provide the reason.

Box 8. Name and Title of Reviewer. Enter full name and title of authorized staff conducting audit review.

Box 9. Signature. Enter signature of authorized reviewer conducting audit.

Box 10. Date. Enter month, day and year when audit was conducted.

Page 2 of 2 ETA Form 9065 (Rev. April 2016)