Eta 9063

U.S. Department Labor

Employment and Training Administration

OMB No. 1205-0371

Expiration Date: August 31, 2018

Employer Certification

Work Opportunity Tax Credit

(OPTIONAL FORMAT)

(OPTIONAL FORMAT) 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. 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
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 or 52 of the Internal Revenue Code of 1986, as amended.
13. NAME OF CERTIFYING OFFICER (Print or Type)			14. SIGNATURE. (Certifying Officer)			15. DATE ISSUED:
Comments to Employers: The Protecting Americans from Tax Hikes Act of 2015 retroactively reauthorized current target groups for a 5-year period, January 1, 2015 through December 31, 2019, and extended the Empowerment Zones designations for a two-year period, January 1, 2015 through December 31, 2016. The Act introduced a new target group, Qualified Long-term Unemployment Recipient (LTUR), for new hires that begin to work for an employer on or after January 1, 2016 – December 31, 2019. For additional information on filing certification requests to the State Workforce Agencies (SWA) and the Long-term Unemployment Recipient eligibility requirements and documentary evidence visit WOTC’s national website at www.doleta.gov/wotc and get an e-copy of TEGL No. xx-xx. Employers are also encouraged to visit IRS’s website at www.irs.gov to obtain e-copies of IRS Notice 2016-22 and the newly revised 2016 IRS Form 8850 and related Instructions. EMPLOYERS: Before you can claim the WOTC, your new hire must work at least 120 hours or 400 hours or more for you to meet the Minimum Employment or Retention Period. Visit IRS’s website at: www.irs.gov for additional information. Note. More information is available in the instructions for IRS Form 8850 & 5884, Work Opportunity Credit, for tax year 2015.
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. April 2016)

INSTRUCTIONS FOR COMPLETING AND ISSUING THE CERTIFICATION FORM (CF) ETA 9063. Documentary evidence of eligibility 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 this 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 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. April2016)