Form ETA-9058 Certification Workload and Characteristic of Certified I

Certification Workload and Characteristics of Certified
Individuals
Work Opportunity Tax Credit - Report No. 1
State:

Quarter Ending:

U.S. Department of Labor

Employment and Training Administration

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 reporting
requirements is mandatory (P.L. 104-188). Public reporting burden for this collection is estimated to average 1 hour 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 or any other aspect of this information collection, including suggestions for reducing this burden to the U.S. Department of Labor, Employment and Training
Administration, Division of National Programs, Tools, &Technical Assistance, 200 Constitution Ave., NW, Room C-4510, Washington, D.C. 20210 (Paperwork Reduction Project
1205-0371).

OMB Control No. 1205-0371
Expiration Date:

PART I. CERTIFICATION WORKLOAD
A) Incomplete
Requests

I) By WOTC Target
Group
1.IV-A TANF Recipient

CERTIFICATION REQUESTS (System Inputs)
B) Requests Needing Action
C) New Requests

(a) No. of CCs
Resulting in
Certifications

2Ba. Veteran Receiving
SNAP benefits (V)
2Bb. Disabled Veteran (DV)
2Bc. DV Unemployed for 6
months

D) Total Requests
to Be Processed

E) Certified Requests

CERTIFICATION REQUESTS (System Outputs)
F) Denied Requests
G)
Incompl
t

PART II. CHARACTERISTICS OF CERTIFIED INDIVIDUALS
(a) No.
Certified
J) By Occupation
J) By Occupation (Cont.)
Individuals

(b) No.
Certified
Individuals

Name-Code

Name-Code

1. Management Occupations – 11

12. Protective Services – 33

2. Business & Financial Operations – 13

13. Food Preparation & Serving – 35
14. Bldg. & Grounds Cleaning &
Maintenance – 37
15. Personal Care & Service - 39

(a) No.
Certified
Individuals

H) Requests Needing Action

K) By Starting
Hourly Wage
1. Under Federal
Minimum Wage
2. $7.25 - $8.25

3. $8.26 – $8.99

2Bd. V Unemployed for 4
weeks

3. Computer & Mathematical – 15

2Be. V Unemployed for 6
months

4. Architecture & Engineering – 17

16. Sales & Related Occupations – 41

5. $10.00 – Higher

5. Life, Physical & Social Sciences – 19

17. Office/Administrative Support – 43

6. TOTAL (For Qtr.)

4. Summer Youth
5. Designated Community
Resident

6. Community & Social Services – 21

18. Farming, Fishing & Forestry – 45

7. Legal Occupations – 23

19. Construction & Extraction – 47

6a. Voc. Rehab Referral

20. Installation/Maintenance/Repair- 49

6b. Ticket Holder

8. Education, Training, & Library – 25
9. Arts, Design, Entertainment, Sports/Media
Occupations – 27

7. SNAP Recipient

10. Healthcare Practitioner & Technical – 29

21. Production Occupations – 51
22. Transportation & Material Moving
Production Occupations – 53

8. SSI Recipient

11. Healthcare Support Occupations – 31

23. Military Specific Occupations – 55

3. Ex-Felon

(a) No.
Certified
Individuals

4. $9.00 -$9.99

9. Long-term TANF
10. LTUR
11. TOTAL (For Qtr.)
12. TOTAL (YTD)
24. Name and Title of Responsible Official:
Page 1 of 5

25. Signature Title:

26. Date Signed:

27. Total (For Qtr.)
ETA Form 9058 (Rev. November 2016)

Instructions for Preparing ETA Form 9058, Report 1 –“Certification Workload and
Characteristics of Certified Individuals,” Work Opportunity Tax Credit Report

Introduction. Part I. of this report clarifies and simplifies data reported on certifications issued
and provides state workforce agencies’ (SWAs) workload numbers during each reporting
quarter. Part II., continues to collect data on selected characteristics of certified individuals.
Form Updates. The Protecting Americans from Tax Hikes Act of 2015 introduced a new WOTC
target group, the Long-term Unemployment Recipient (LTUR), see Box 10.
Background. The purpose of ETA Form 9058 is to provide SWAs with a standardized ereporting format, which accurately reflects program activity levels and outcomes under the Work
Opportunity Tax Credit (WOTC). It is important for SWAs to maintain programmatic reporting
procedures that account for each tax request (IRS Form 8850) received and its subsequent
outcome (issuance of a tax certification or denial). A properly completed ETA Form 9058
accurately reflects program use and the level of any programmatic backlog that may exist. To
ensure that the WOTC Program can be evaluated accurately at the national level, it is critical that
all SWAs report in a standardized manner using the web-based Enterprise Business Service
System (EBSS) Tax Credit Reporting System (TCRS).

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ETA Form 9058 (Rev. November 2016)

INSTRUCTIONS FOR COMPLETING THIS FORM:
State. Enter the name of the state submitting ETA Form 9058.
Quarter Ending Period. Enter ending date of the quarter for the reported program data.
Part I. "Certification Workload.” SWAs must identify from Part I, Item F on the previous reporting quarter's ETA
Form 9058 the number of requests (IRS Form 8850s) determined to be incomplete or Needing Action, as defined
below:
Number of Requests Incomplete. Enter the total number of requests (IRS Form 8850s) received by the
SWA prior to the beginning of the current report period, but for which no applicant eligibility determination action
(excluding the 48-hour review) was taken. This total is to be entered into Part I, Item (A) of ETA Form 9058.

(A)

Number of Requests Needing Action. Enter the total number of requests (IRS Form 8850s) received by
the SWA prior to the beginning of the current report, but for which no review and total is to be entered into Part I,
Item (B) of recently revised ETA Form 9058.
(B)

New Requests. Enter the total number of requests (IRS Form 8850s) received by the SWA during the
current reporting quarter. Some states may have received requests (IRS Form 8850s) that were not
previously recorded and/or reported on any prior quarterly report ETA 9058 for various reasons. It is Important for
the SWA to report all requests (IRS Form 8850s) received. Therefore, any request received outside of the current
reporting quarter, which has not previously been reported, should be included with the number of requests
received during the current reporting period. That total should be entered as the number of "New Requests". This
total is to be entered into Part I, Item (C) of ETA Form 9058.
(C)

Total Requests to Be Processed. Enter the sum of Items A, B & C. This total represents the
number of requests (IRS Form 8850s) received by the SW A, which are available to be processed. This
total is to be entered under Part I, Item (D) of ETA Form 9058. Note. A denial is a certification request (IRS
Form 8850) determined by the SWA to be ineligible for the WOTC.
(D)

(E)

Requests Certified. Enter the total number of WOTC certifications issued during the current report period.

Requests Denied. Enter the total number of requests (IRS Form 8850s) denied by the SWA during the
current report period.
(F)

Note. A denial is a request (IRS Form 8850) determined by the SWA to be ineligible for the WOTC.
(G) Number of Requests Incomplete. Enter the total number of requests (IRS Form 8850s) received
and reviewed by the SW A, but which the SW A could neither approve nor deny due to such things as,
but not limited to, the need for additional eligibility documentation for which the SWA has made a
formal request to the employer, authorized tax consultant, or other third party entity, ETA Form 9061
not submitted, etc.
Note. This number will also be entered in Part 1, Item A. of the subsequent quarterly report ETA
Form 9058.

Number of Requests Needing Action. Enter the number of requests (IRS Form 8850s) received by the SWA
but for which no review and/or action has yet been taken to determine applicant eligibility.
(H)

Note. This value will also be entered in Part I, Item B. of the subsequent quarterly report ETA Form 9058.
Part I, Item H is the sum of Item D, minus Item E, minus Item F, minus Item G.
Part I. Completion Formula:
(A +B + C) = D and
D – (E + F + G) = H Same as: Items (A+B+C) = D and (D-E-F-G) = H
Part II. "Characteristics of Certified Individuals by Tax Credit." This part is divided into three sections
(Section I, Section J, and Section K).
Section I reflects the number of requests (IRS Form 8850s) certified by the SWA during the current report period
by WOTC target groups. Section J reflects the number of requests (IRS Form 8850s) certified by the SWA
during the current report period by occupation. Section K reflects the number of requests (IRS Form 8850s)
certified by the SWA during the current report period by starting hourly wage.

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ETA Form 9058 (Rev. November 2016)

Section I.
Section I, Column (a). Enter the total number of certifications, issued by the SWAs, by target group, during
the current report period, which resulted from the issuance of a conditional certification i.e., ETA Form 9062.
Section I, Column (b). Enter the total number of WOTC certifications issued by the SWAs, by target
group, during the current report period.
Section I, Line #1. Enter the total number of WOTC certifications issued by the SWA during the current
report period, for the IV-A TANF group.
Section I, Line #2Ba. Enter the total number of WOTC certifications issued by the SWA during the
current report period, for Veterans receiving SNAP benefits.
Section I, Line #2Bb. Enter the total number of WOTC certifications issued by the SWA during the current
report period, for “Disabled Veterans” receiving compensation for a service-connected disability.
Section I, Line #2Bc. Enter the total number of WOTC certifications issued by the SWA during the current
report period, for Disabled Veterans unemployed for 6 months.
Section I. Line #2Bd. Enter the total number of WOTC certifications issued by the SWA during the current
report period, for Veterans unemployed for at least 4 weeks but less than 6 months.
Section I. Line #2Be. Enter the total number of WOTC certifications issued by the SWA during the
current report period, for Veterans unemployed for at least 6 months.
Section I. Line #3. Enter the total number of WOTC certifications issued by the SWA during the current report
period, for Ex-felons.
Section I. Line #4. Enter the total number of WOTC certifications issued by the SWA during the current
report period for the Summer Youth group
Section I, Line #5. P.L. 110-28 changed the name of the High-Risk Youth to “Designated Community
Residents (DCRs).” Enter the total number of WOTC certifications issued by the SWA during the current report
period, for DCRs.
Section I, Line #6a. Enter the total number of WOTC certifications issued by the SWA during the current
report period, for Vocational Rehabilitation Referrals.
Section I, Line #6b. Enter the total number of WOTC certifications issued by the SWA during the current
report period, for “ticket holders.” (e.g., SSDI, or Voc. Rehab -- formerly called People with Disabilities).
Section I, Line #7. Enter the total number of WOTC certifications issued by the SWA during the current
report period, for SNAP (formerly Food Stamps) recipients.
Section I, Line #8. Enter the total number of WOTC certifications issued by the SWA during the current report
period, for SSI recipients.
Section I, Line #9. Enter the total number of WOTC certifications issued by the SWA during the current report
period, for “Long-term TANF” Recipients.
Section I, Line #10. Enter the total number of WOTC certifications issued by the SWA during the current report
period, for “Long-term Unemployment Recipients” (LTURs).
Section I, Line #11. Enter the sums of columns (a) and (b) and also the federal program current Quarter (For
Qtr.) Totals of columns (a) and (b) for Column I. “By WOTC Target Group;” and for Column J. “By
Occupation,” Line # 27. Total (For Qtr.) and for Column K. B y S t a r t i n g H o u r l y W a g e ” L i n e #
6 ( F o r Q t r . ) . Note. The first quarterly report of the federal program year (October 1-December 31), the
totals of Section I, Line #11 (For Qtr.) and Line #12 (YTD) should be the same. Also, the total (For Qtr.) of Part II,
Section I, Line #12, columns (a) & (b) should equal the total entered in Part I. Item E. Certified Requests.
Section I, Line #12. After Quarter 1, for all subsequent quarters enter the cumulative federal program
Year-to-Date (YTD) totals of columns (a) and (b). (including totals for Column I, Column J, and Column K (right
hand side of this form). R e m i n d e r . The first quarterly report of the federal program year (October 1December 31), the totals of Section I, Line #11 and Line #12 should be the same.

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ETA Form 9058 (Rev. November 2016)

Section J.
Section J, Column (a). Enter the total number of WOTC Certifications issued by the SWA during the current
report period, By Occupation. Note: The total for Section J, Column (a), Line #27 is the sum of the column
and must equal the total for Section I, Column (a) & (b) Line # 10.
The occupational data reported in Boxes 1-23 are derived from the job titles reported on ETA Forms 9061
or 9062. To prepare this report, SWAs must use the O*NET job families of occupations and their two-digit
corresponding codes as illustrated in the following table.

O*NET SOC JOB FAMILIES
Code

Name

Name

Management Occupations

11

Business & Financial Operations

13

Computer& Mathematical Occupations
Architecture & Engineering

15
17

Life, Physical & Social Sciences

19

Community & Social Services
Legal Occupations

21
23

Education, Training, & Library

25

Arts, Design, Entertainment, Sports and Media Occupations

27

Healthcare Practitioner & Technical

29

Healthcare Support Occupations
Protective Service Occupations

31
33

Code

Food Preparation &
Serving Related
Bldg. & Grounds Cleaning &
Maintenance
Personal Care & Service
Sales & Related Occupations
Office & Administrative
Support
Farming, Fishing, Forestry
Construction & Extraction
Installation, Maintenance
& Repair
Production Occupations
Transportation & Material
Moving
Military Specific
Occupations

35
37
39
41
43
45
47
49
51
53
55

Section K
Section K, Column (a). Enter the total number of W OTC certifications issued by the SW A during the
current report period, “By Starting Hourly Wage.” Note. The TOTAL (For Qtr.) for Section K, Column (a),
Line #6 is the sum of the column for that quarter and must equal the total for Section I, column (b)
“Number Certified Individuals,” Line #11.
Convert as follows:
Unit of Time
Day
Week
Month

Calculated Hourly W age
Amount divided by 8
Amount divided by 40
Amount divided by 172

24. Name and Title of Responsible Official. Enter the name and title of the authorized signatory official.
25. Signature. Enter the signature of the authorized signatory official.

1

According to the Fair Labor Standards Act (FLSA), the federal minimum wage is $7.25 per hour effective
July 24, 2009. Source: W age and Hour Division at the U.S. Department of Labor.
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ETA Form 9058 (Rev. November 2016)