ETA-9062 Conditional Certification Work Opportunity Tax Credit

OMB Control No. 1205-0371
Expiration Date:

U.S. Department Labor

Employment and Training
Administration
EMPLOYERS

Conditional Certification
Work Opportunity Tax Credit

 This form must be accompanied by IRS Form 8850.
 If you do not have IRS Form 8850, call 202-693-2786 for a copy or download it from www.irs.gov or www.doleta.gov/wotc
 Be sure to complete Part II of this form and IRS 8850, sign and date both forms BEFORE sending them to the
State Workforce Agency (SWA) within 28 days after the new hire’s employment-start date. (See IRS Relief Period in TEGL No. XXXXX and IRS Notice 2016-22)
2. CONTROL NO.
1. INITIATING AGENCY CODE
(For Agency Use Only)

__________________________________
(For Agency Use Only) Check “” One):

____ Participating Agency
____ SWA

CODE: ___________

3. FOR EX-FELON TARGET GROUP ONLY
a. Conviction Date: _________________
No.___________
b. Release Date: ___________________
5. STATE WORKFORCE AGENCY’s
NAME/ADDRESS

4. DATE COMPLETED (MM/DD/YY)
c. Correction’s (Ex-felon’s) ID

6. SIGNATURE (Authorized Official)

__________________________
7. TELEPHONE No.

PART I. APPLICANT’S INFORMATION AND CONDITIONAL CERTIFICATION (CC):
8. NAME OF APPLICANT (Last, First,
Middle)

9. SOCIAL SECURITY No.

10. ENTER TARGET GROUP CODE
AND GROUP NAME FOR HIRES
OTHER THAN “Veteran”:
________________________________

11. ADDRESS (Street, City, State, Zip
Code) &Telephone No.

12. VETERAN TARGET GROUP CODES (Check “” One):
 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
13. APPLICANT SIGNATURE:

NOTE TO EMPLOYERS:
14. The above named individual may be

Note. In the event you hire this individual, you should request the Certification necessary
for you to claim a Work Opportunity Tax Credit (WOTC). Simply complete, sign, and
submit this form together with IRS Form 8850 to the SWA. For new hires that begin to
work for an employer on or after January 1, 2015, and on or before May 31, 2016,
this form can be completed, signed, and submitted together with IRS Form 8850
to the SWA by June 29, 2016. For new hires with an employment start date on or
after June 1, 2016, employers must meet the 28-day timely filing requirement. The
WOTC Employer Certification will be sent to you, if all statutory target group eligibility
and timely filing requirements have been met.

eligible for certification under the Work
Opportunity Tax Credit. If individual is
not employed before the date in the box
below (Mo., Day, Yr.), this eligibility
determination is subject to review.
Applies to Summer Youth group
only.
PART II. EMPLOYER DECLARATION: I, hereby, declare that the above named person is or will be employed by:
15. NAME OF FIRM AND
ADDRESS:

16. POSITON/JOB TITLE:

17. EMPLOYMENT-START
DATE:

18. STARTING WAGE:
$ ___________ per hr

ATTN SWA: Please send a WOTC Certification for this employee. The pre-certification is for the purpose of requesting
Certification to obtain the WOTC under Sec. 51 and 52 of the Internal Revenue Code. Employers are advised that such credit will
cease immediately upon notification of any subsequent invalidation/revocation.
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.
19. EMPLOYER’S NAME:
20. EMPLOYER’S SIGNATURE:
21. DATE: ((MM/DD/YY)

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ETA Form 9062 (Rev. November 2016)

CONDITIONAL CERTIFICATION (CC) ETA FORM 9062. When a SWA or participating agency (PA) determines that
a job-ready applicant is, TENTATIVELY ELIGIBLE as a member of a target group under WOTC, it shall use this required
form, without modification, to show that eligibility pre-determination was made for this person. Note. The CC serves as an
official record of the pre-certification, alerts prospective employers to the availability of the tax credit if this individual is hired, and
provides a means for employers to request a WOTC certification for this person.
INSTRUCTIONS FOR COMPLETING THE “CONDITIONAL CERTIFICATION” FORM. (Boxes 1-8 and 15 are for participating
agency (PA) and SWA use only)
Box 1:

Initiating Agency Code. If the CC was issued by a Participating Agency (PA), enter its code.. SWAs assign codes to
designate each PA and indicate the initiating source for the eligibility determination process. If the eligibility
determination was performed by the SWA, enter the SWA’s code, if available. Indicate with a check mark “” if initiating
agency is a PA or SWA.

Box 2:

Control Number. Usually the PA determines the control number (CN). However, SWAs may, for internal control purposes,
develop their own CN system. It may be a case number or some other appropriate designation (e.g., alpha-numeric
designation), which permits easy filing, certification and retrieval of forms. Enter corresponding CN and indicate with a check
mark “” whether the source is a PA or a SWA.

Box 3:

For Ex-Felon Target Group Only. For items a - c, enter the corresponding information. This information will help the SWA or
PA in verifying target group eligibility.

Box 4:

Date Completed. Enter the month, day, year in which the eligibility determination was completed.

Box 5:

SWA’s Name and Address. If known, enter or stamp the name and address, including zip code, of the SWA responsible for
Certification requests for the employer indicated in Box 156. Leave blank if SWA’s name and address is unknown.

Box 6:

Signature. Enter signature of the authorized conditionally-certifying official.

Box 7:

Telephone No. Enter corresponding SWA or PA area code, telephone number and extension, if available.

PART I.

APPLICANT’S INFORMATION AND CONDITIONAL CERTIFICATION (CC):

Box 8:

Name of Individual. Enter the individual’s/ applicant’s full name (i.e., last name, first name and middle initial).

Box 19:

Social Security Number. Enter the individual’s/applicant’s Social Security Number.

Box 10:

Target Group Code. Enter the code or name of the pre-certified target group other than Veteran. 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.

Box 11:

Address/Telephone No. Enter the individual’s/applicant’s home address, including apartment number and zip code. After
address, enter individual’s telephone number, including area code.

Box 12:

Veteran Target Group Code. The 1996 original target group designation for a Qualified Veteran is “B.” To facilitate the
identification of the different veteran categories created by the VOW to Hire Heroes Act of 2011 (P.L. 112-56,), ETA uses the
same alpha-numeric designations to collect the number of certifications issued for the amended veteran categories in ETA
Form 9058 – Report 1. To ensure a simple, uniform and consistent certification system which can be used by the SWAs
nationwide each new veteran category is preceded by “B” and followed by the alpha-numeric code used in ETA Form 9058.
Enter a check mark “” in front of the veteran group pre-certified.

Box 13:

Signature. Get applicant’s signature. If a minor, parent or guardian must sign here.

Box 14:

CC Validity Period. (This box is to be completed by the SWA or PA). Enter the month/day/year when the CC expires.
This box does not apply to veterans pre-certified under the VOW to Hire Heroes Act of 2011. This box applies only to
the Summer Youth target group.

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ETA Form 9062 (Rev. November 2016)

Box 15:

Name of Firm. Enter full name of the employing firm (the firm where the employee will actually work).

Box 16:

Position/Job Title. Enter the position or job title the employee will hold.

Box 17:

Employment-Start Date. Enter the date the employee began or will begin work for the employing firm.

Box 18:

Starting Wage. Enter the wage or salary which the employee will be paid. If not known, enter an estimated wage.

Box 19:

Employer’s Name. Enter your name as the hiring employer.

Box 20:

Employer’s Signature. Affix your electronic or ink signature here.

Box 21:

Date. Enter month, day and year when you signed this form.

Persons are not required to respond to this collection of information unless it displays a currently valid OMB Control Number.
Respondents’ obligation to reply to these questions is required for obtaining the tax credit per P.L. 104-188. Public reporting burden
for this collection of information is estimated to average 20 minutes per response, including the time for reading instruction, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing the
burden to the U.S. Department of Labor, Employment and Training Administration, Division of National Programs, Tools, and
Technical Assistance, 200 Constitution Ave., NW, Room C-4510, Washington, D.C. 20210 (Paperwork Reduction Project 12050371)

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.

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ETA Form 9062 (Rev. November 2016)