Eta-9175 Long-term Unemployment Recipient Self-attestation Form W

OMB Control No. 1205-0371

Expiration Date: March 31, 2023

U.S. Department Labor

Employment and Training Administration

LONG-TERM UNEMPLOYMENT RECIPIENT (LTUR)

SELF-ATTESTATION FORM (SAF)

Work Opportunity Tax Credit

Instructions: The Self-Attestation Form (SAF) is to be completed, signed, and dated by the applicant / new hire, only. Employers or consultants should submit the completed SAF along with IRS Form 8850, or if filed separately, with ETA Form 9061 (or ETA Form 9062), to the State Workforce Agency (SWA) for each certification request filed for the Long-Term Unemployment Recipient (LTUR) targeted group.

Applicant Self-Attestation: Under penalties of perjury, I declare that the information below is true and correct to the best of my knowledge.

Applicant’s Full Name (Print: First, Middle Initial, Last): ____________________________________

Applicant’s Signature: _______________________________________ Date:_______ ______

Applicant’s Social Security Number: Date of Birth: ______________

(MM/DD/YYYY)

Employer’s Name: ___________________________________________________________

Employer’s Firm/Company Name: _______________________________________ .

Applicant Instructions: Please check “√” the statement below if it applies to you and complete the requested information.

 I declare that I was/am in a period of unemployment that was/is at least 27 consecutive weeks; and, for all or part of that unemployment period, I received unemployment compensation under State or Federal law.

State(s) unemployment compensation was received: .

I have been in a period of unemployment since: .

(Enter unemployment start date, mm/dd/yyyy)

Privacy Act Notice:

Section 51 of the Internal Revenue Code of 1986, 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 you have provided by 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 to determine your employer's eligibility for the federal work opportunity tax credit.   

Public Burden Statement:

Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Respondents' obligation to complete this Form is required to obtain or retain benefits (P.L. 111-5). Public reporting burden is estimated to average 10 minutes 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 to the U.S. Department of Labor, Division of National Programs Tools Technical Assistance, Room C-4510, Washington, D.C. 20210 (Paperwork Reduction Project 1205-0371). Please do not submit completed WOTC processing forms to this address.

ETA Form 9175 (Rev. Feb 2023)