ETA-9065 Agency Declaration of Verification Results (ADVR) Worksh

Work Opportunity Tax Credit
(For SWAs’ Internal Use Only)

1. NAME OF INDIVIDUAL

U.S. Department of Labor

Employment and Training Administration

Agency Declaration of Verification
Results (ADVR) Worksheet

OMB Control No. 1205-0371
Expiration Date:
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)

5. DATE CERTIFIED:

✔ Participating Agency or ___ SWA
CC Issued By: ___
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. 104188, 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 9065 (Rev. November 2016)

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

If review of documentation reveals that the certified individual is eligible, enter a check mark“.”
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.
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ETA Form 9065 (Rev. November 2016)