Form ETA 9175

OMB Control No. 1205-0371

Expiration Date: NovemberAugust 301, 20168

U.S. Department Labor

Employment and Training Administration

LONG-TERM UNEMPLOYMENT RECIPIENT SELF-ATTESTATION FORM

Work Opportunity Tax Credit (WOTC) Program

Instructions: This Self-Attestation Form (SAF) is to be completed, signed, and dated by the new hire only. Employers or consultants submit this SAF to the State Workforce Agency with IRS Form 8850 or if filed separately, with ETA Form 9061 (or ETA Form 9062) for each certification request filed for the new target group.

Under penalties of perjury, I declare that this information is true and correct to the best of my knowledge.

New Hire’s Signature: __________________________________________Date_____________

New Hire Name: ___________________________________________________________

Social Security Number: - Date of Birth: ___________________

(Enter last four digits) (Enter date)

Employer Name: ___________________________________________________________

Employer Federal ID (EIN) Number: __________________________________-

(Enter last four digits)

Please check all the statementss below if they applyiethat apply to you. and provide all requested dates . Sign and date this form where indicated below.

 I declare that I was in a period of unemployment that is at least 27 consecutive weeks and for all or part of that period I received unemployment compensation.I declare that I was in a period of unemployment that is at least 27 consecutive weeks the day before I began to work for this employer, or, if earlier, the day I completed IRS Form 8850. I have been in a period of unemployment of not less than 27 consecutive weeks, from _________________ to __________________.

(Enter start date) (Enter end date)

I make this declaration on the day I completed IRS Form 8850 _________________.

(Enter date)

•  I declare that have been in a period of unemployment since

___________________.

(Enter start date)

I declare I have received unemployment compensation/benefits under State or Federal law during a period of unemployment.

Privacy Act Notice:

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 to determine your employer's eligibility for the federal tax credit.   

Public Burden Statement:

Persons are not required to respond to this collection of information unless it displays a currently valid OM B control number. Respondents' obligation to complete this form is required to obtain or retain benefits (P.L. 111-5). Public reporting burden is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of Information. Send comments regarding this burden estimate to the U.S. Department of Labor, Division of National Programs Tools Technical Assistance, Room C-4510, Washington, D.C. 20210 (Paperwork Reduction Project 1205-0371). Please do not submit completed forms to this address.

ETA Form 9175 (NovemberMay 2016)