ETA-9063 Employer Certification Work Opportunity Tax Credit

U.S. Department Labor

Employment and Training Administration

OMB Control No. 1205-0371

Expiration Date: March 31, 2026

Employer Certification

Work Opportunity Tax Credit

(OPTIONAL FORMAT)

STATE WORKFORCE AGENCY (AGENCY) INFORMATION
1. NAME, ADDRESS & TELEPHONE NO. OF CERTIFYING AGENCY:		2. CONTROL NO. (For Agency Use Only)	3. DATE COMPLETED: (mm/dd/yyyy)
		4. INITIATING AGENCY CODE: (For Agency Use Only)
PART A. EMPLOYER INFORMATION
5. NAME, ADDRESS & TELEPHONE NO. OF EMPLOYER’S FIRM/COMPANY:	6. EMPLOYER IDENTIFCATION NO. (EIN):		7. EMPLOYER REPRESENTATIVE’S NAME, TITLE & ADDRESS (if applicable):
PART B. EMPLOYEE INFORMATION
8. SOCIAL SECURITY NO.: ___________________	9. EMPLOYMENT START DATE: (MM/DD/YYYY)
10. NAME AND ADDRESS OF EMPLOYEE:	12. VETERAN TARGETED GROUP CODES: (“” check those that apply) 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
11. TARGETED GROUP CODE AND NAME: (Enter Non-Veteran targeted groups, only): ________________________________________
Note to Employers: For additional information on filing WOTC certification requests with State Workforce Agencies (SWA), visit the DOL.gov WOTC website at https://www.dol.gov/agencies/eta/wotc. Employers are also encouraged to visit the IRS.gov website at https://www.irs.gov/forms-pubs/about-form-8850 to obtain copies of the newly revised IRS Form 8850. Before employers may claim the work opportunity credit, the employee (new hire) must perform at least 120 hours of service for the employer to meet the Minimum Employment or Retention Period. See the FAQ for additional information: https://www.irs.gov/businesses/small-businesses-self-employed/work-opportunity-tax-credit.
PART C. AGENCY CERTIFICATION
I, HEREBY, CERTIFY that the individual named in Part B meets the eligibility criteria of Section 51(d) of the Internal Revenue Code of 1986, as amended.
13. NAME OF CERTIFYING OFFICER: (Print or Type)	14. SIGNATURE: (CERTIFYING OFFICER)			15. DATE ISSUED:
NOTE: Falsification of data to obtain this Certification is a FEDERAL CRIME in violation of 18 USC 1001. Falsification of work or concealment of information is PUNISHABLE by a fine or imprisonment.

INSTRUCTIONS FOR COMPLETING AND ISSUING THE EMPLOYER CERTIFICATION - ETA FORM 9063

Documentary evidence and/or collateral contacts is required to determine applicant targeted group eligibility and issue a WOTC Employer Certification. Issuance of an Employer Certification validates the new hire/employee’s targeted group eligibility under Section 51 of the Internal Revenue Code of 1986, as amended, and it confirms the employer is entitled to claim the work opportunity credit against the qualified wages paid to the new hire. See the Instructions to IRS Form 5884 and IRS Form 5884-C for more information. 

Note: It is not the responsibility of the SWAs to verify that an employee certified to be a member of a targeted group has worked the required number of hours for the employer, under section 51(i)(3) of the Code. SWAs are only responsible for verifying and certifying an applicant’s eligibility as a member of a targeted group. The responsibility for verifying the required number of hours worked rests with the IRS.

The Employer Certification should be completed in entirety by an authorized official of the state workforce agency or certifying agency. See instructions below for each of the Boxes to be completed by the SWA:

Box 1. Name and Address. Identify the SWA and include the appropriate address and zip code.

Box 2. Control Number. Enter the control number developed by the SWA for its own use.

Box 3. Date Completed. Enter the month, day and year when the form was completed.

Box 4. Initiating Agency Code. Enter agency code developed by SWA for its own use.

Box 5. Name and Address of Firm. Enter employer's company name and address, including zip code.

Box 6. Employer Identification Number (EIN). Enter employer’s federal taxpayer identification number.

Box 7. Representative's Name, Title and Address. Enter the name, title and office location of the individual authorized by the employer to act on the employer’s behalf.

Box 8. Social Security No. Enter the employee's social security number.

Box 9. Employment Start Date. Enter the month, day and year when the employee began to work for the employing firm.

Box 10. Name and Address of Employee. Enter the employee's full name (i.e., last name, first name and middle initial) and mailing address, including zip code, and telephone number, if available.

Box 11. Targeted Group. Enter SWA Code and targeted group name for the certified group.

Box 12. Veteran Targeted Group. Indicate with a checkmark (“”), which veteran subgroup the employee (new hire) is being certified under.

Box 13. Certifying Official. Enter full name and title of authorized certifying official.

Box 14. Signature. Enter authorized, certifying official's signature.

Box 15. Date. Enter date (mm/dd/yyyy) when the Employer Certification is issued by the certifying agency.

Persons are not required to respond to this collection of information unless it displays a currently valid OMB Control Number. Respondent's obligation to reply to these requirements is mandatory under 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 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 U.S. Department of Labor, Division of National Programs, Tools, and Technical Assistance, Room C-4510, Washington, D.C. 20210 (Paperwork Reduction Project Control No. 1205-0371).

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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 process. The information applicants (new hires) have provided associated WOTC processing forms will be disclosed to the State Workforce Agency.  Provision of this information is voluntary, however; the information is required for employers to receive the federal work opportunity tax credit. 

IF THE INFORMATION YOU PROVIDE IS ABOUT A MEMBER OF YOUR FAMILY, YOU SHOULD PROVIDE HIM/HER A COPY OF THIS NOTICE.

Page 1 of 2 ETA Form 9063 (Rev. Feb 2023)