Work Opportunity Tax Credit

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form ETA-9061 Individual Characteristics Form (ICF) Work Opportunity Tax Credit	Form and Instruction	Modified	Available
Form ETA-9065 Agency Declaration of Verification Results (ADVR) Worksheet	Form and Instruction	Modified	Available
Form ETA-9063 Employer Certification Work Opportunity Tax Credit	Form and Instruction	Modified	Available
Form ETA-9062 Conditional Certification Work Opportunity Tax Credit	Form and Instruction	Modified	Available
Form ETA-9061 Individual Characteristics Form (ICF) Work Opportunity Tax Credit	Form and Instruction	Modified	Available
Form ETA-9058 Certification Workload and Characteristic of Certified Indivduals	Form	New	Available
Form ETA-9175 LONG-TERM UNEMPLOYMENT RECIPIENT SELF-ATTESTATION FORM Work Opportunity Tax Credit (WOTC) Program	Form and Instruction	Modified	Available
Form ETA-9061 Individual Characteristics Form (ICF) Work Opportunity Tax Credit	Form and Instruction	Modified	Available
Form ETA-9062 Conditional Certification Work Opportunity Tax Credit	Form and Instruction	Modified	Available
Form ETA-9061 Individual Characteristics Form (ICF) Work Opportunity Tax Credit	Form and Instruction	Modified	Available
BILLS-114hr2029enr see p815.pdf	Supplementary Document	Uploaded 2016-04-20	Available
1205-0371 Supporting Statement OCCC 010820.doc	Supporting Statement A	Uploaded 2020-01-08	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
43791	Work Opportunity Tax Credit (WOTC)	Form and Instruction	Modified	Individual Characteristics Form (ICF) Work Opportunity Tax Credit
43791	Work Opportunity Tax Credit (WOTC)	Form and Instruction	Modified	Agency Declaration of Verification Results (ADVR) Worksheet
43791	Work Opportunity Tax Credit (WOTC)	Form and Instruction	Modified	Employer Certification Work Opportunity Tax Credit
43791	Work Opportunity Tax Credit (WOTC)	Form and Instruction	Modified	Conditional Certification Work Opportunity Tax Credit
43791	Work Opportunity Tax Credit (WOTC)	Form and Instruction	Modified	Individual Characteristics Form (ICF) Work Opportunity Tax Credit
239192	Certification Workload and Characteristic of Certified Individuals	Form	New	Certification Workload and Characteristic of Certified Indivduals
221431	Qualified Long-term Unemployment Recipient (LTUR)	Form and Instruction	Modified	LONG-TERM UNEMPLOYMENT RECIPIENT SELF-ATTESTATION FORM Work Opportunity Tax Credit (WOTC) Program
184551	Individual Characteristics	Form and Instruction	Modified	Individual Characteristics Form (ICF) Work Opportunity Tax Credit
184551	Individual Characteristics	Form and Instruction	Modified	Conditional Certification Work Opportunity Tax Credit
184551	Individual Characteristics	Form and Instruction	Modified	Individual Characteristics Form (ICF) Work Opportunity Tax Credit

ICR Details

OMB Control No: 1205-0371	ICR Reference No: 201912-1205-010
Status: Historical Active	Previous ICR Reference No: 201611-1205-003
Agency/Subagency: DOL/ETA	Agency Tracking No:
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 with change	Conclusion Date: 03/03/2020
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/31/2020
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2023	36 Months From Approved	03/31/2020
Responses	13,527,028	0	5,840,620
Time Burden (Hours)	4,454,205	0	1,960,777
Cost Burden (Dollars)	0	0	0

---

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 November 2016 - Certification Workload and Characteristics of Certified Individuals • ETA Form 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

---

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
   PL: Pub.L. 104 - 188 2242 Name of Law: Small Business Job Protection Act of 1996
   PL: Pub.L. 113 - 114 1755 Name of Law: Protecting Americans from Tax Hikes Act of 2015
   US Code: 26 USC 2242 Name of Law: Small Business Job Protection Act of 1996
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 56204	10/21/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 5254	01/29/2020
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 4

table that charts list of burden

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

---

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	13,527,028	5,840,620	0	208	7,686,200	0
Annual Time Burden (Hours)	4,454,205	1,960,777	0	208	2,493,220	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The burden hours significantly increased for this burden statement reporting due to incorporating the WOTC denial rate which has not been factored in historically. DOL/ETA believes this more accurately reflects the full total number of respondents.

---

Annual Cost to Federal Government: $11,050

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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

---

Common Form ICR:  No

---

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: 01/31/2020

---