ETA-9062 Tracked Changes

U.S. Department of Labor

Employment and Training Administration

OMB No. 1205-0371

Expiration Date: March 31, 2026

Conditional Certification Form (CC)

Work Opportunity Tax Credit

INSTRUCTIONS FORM EMPLOYERS: This form must be accompanied by IRS Form 8850. If you do not have IRS Form 8850, download it from https://www.irs.gov. 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 reverse side for additional Form instructions.
PARTICIPATING AGENCY / STATE WORKFORCE AGENCY (SWA) INFORMATION:
1. INITIATING AGENCY CODE (For Agency Use Only) CODE: ___________	2. CONTROL NO.: (For Agency Use Only) __________________________________ Check “” One: ____ SWA ____ Participating Agency		3. DATE COMPLETED: (MM/DD/YY) __________________________
4. STATE WORKFORCE AGENCY’S NAME / ADDRESS	5. TELEPHONE NUMBER		6. AUTHORIZED SIGNATURE (Agency / SWA Official) __________________________
PART I. APPLICANT’S INFORMATION AND CONDITIONAL CERTIFICATION (CC):
7. NAME OF APPLICANT (Last, First, Middle)	8. APPLICANT’S ADDRESS & TELEPHONE NUMBER: (Include Street, City, State, Zip Code)		9. APPLICANT’S SOCIAL Security NO. ___ ________
10. ENTER TARGETED GROUP CODE / TARGETED GROUP NAME (for the applicant seeking certification): ________________________________	11. VETERAN TARGETED 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
12. FOR EX-FELON TARGETED GROUP: a. Federal or State: . b. Conviction Date: _________________ c. Release Date: ___________________ d. Correction’s (Ex-felon’s) ID No. : ____________________________________	13. FOR SUMMER YOUTH EMPLOYEE TARGETED GROUP: The above-named applicant may be eligible for Work Opportunity Tax Credit (WOTC) certification. If the individual is not employed before the date in the box above (MM/DD/YY), this eligibility determination is subject to review.
14. APPLICANT’S SIGNATURE: DATE: .
Note to Employers: In the event that you hire this individual, you should request the necessary Certification from the SWA for you to claim the Work Opportunity Credit. Complete, sign, and submit this Form together with IRS Form 8850 to the SWA in which your business is located. IRS Form 8850 must be submitted to the SWA within 28 calendar days of the new hire’s start date to meet timely filing requirement. If all statutory targeted group eligibility and timely filing requirements have been met for your certification request, the SWA will issue you an Employer Certification.
PART II. EMPLOYER DECLARATION: I hereby declare that the above-named applicant is or will be employed by the date provided in box 16. 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.
15. NAME OF FIRM/COMPANY AND MAILING ADDRESS:		16. APPLICANT’S EMPLOYMENT START DATE (MM/DD/YY): .		17. POSITON / JOB TITLE: 18. STARTING WAGE: $ ___________ per hr
ATTN SWA: Please send a WOTC Employer Certification for this employee. The pre-certification is for the purpose of requesting Certification to obtain the Work Opportunity Credit 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.
19. EMPLOYER’S NAME:	20. EMPLOYER’S SIGNATURE:			21. DATE: (MM/DD/YY)

CONDITIONAL CERTIFICATION (CC) ETA FORM 9062. When a state workforce agency (SWA) or participating agency (PA)

determines that a job-ready applicant is tentatively ELIGIBLE as a member of a targeted group under WOTC, the agency shall

use this required CC Form, without modification, to show that eligibility pre-determination was made for the applicant.

Note: The CC serves as an official record of the pre-certification, alerts prospective employers to the availability of the tax credit if the

applicant is hired, and provides a means for employers to request a WOTC Employer Certification for the applicant.

INSTRUCTIONS FOR COMPLETING ETA FORM 9062, CONDITIONAL CERTIFICATION:

BOXES 1 - 8 ARE FOR PARTICIPATING AGENCY / STATE WORKFORCE AGENCY (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. 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 code), 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: Date Completed. Enter the month, day, year in which the eligibility determination was completed

Box 4: SWA’s Name and Address. If known, enter or stamp the name and address, including zip code, of the State Workforce Agency (SWA) responsible for processing certification requests for the employer indicated in Box 15. Leave blank if SWA’s name and address is unknown.

Box 5: Telephone No. Enter corresponding SWA or PA area code, telephone number and extension, if applicable.

Box 6: Signature. Enter signature of the authorized conditionally-certifying official.

PART I. APPLICANT’S INFORMATION AND CONDITIONAL CERTIFICATION (CC):

Box 7: Name of Applicant. Enter the individual’s/job applicant’s full name (i.e., last name, first name and middle initial).

Box 8: 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 9: Social Security Number. Enter the individual’s/applicant’s Social Security Number, as it appears on their Social Security Card.

Box 10: Targeted Group Code. Enter the code or name of the pre-certified targeted group.

For targeted group names and eligibility definitions, visit https://www.irs.gov/businesses/small-businesses-self-employed/work-opportunity-tax-credit#targeted.

Box 11: Veteran Targeted Group Codes. The original targeted group designation for a Qualified Veteran is “B.” To facilitate the identification of the different subcategories of qualified veterans created by the VOW to Hire Heroes Act of 2011 (P.L. 112-56), and to ensure a simple, uniform and consistent certification system which can be used by the SWAs nationwide, ETA uses the same alpha-numeric designations for the qualified veteran categories used in ETA Form 9058, WOTC Report 1. Each 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 qualified veteran subgroup for which the applicant is pre-certified.

Box 12: For Ex-Felon Targeted Group Only. For items a - d, enter the corresponding information. This information will help the SWA or PA in verifying targeted group eligibility.

Box 13: CC Validity Period (For Summer Youth Employee Targeted Group Only). This box is to be completed by the SWA or PA). Enter the month/day/year when the Conditional Certification expires. This box does not apply to qualified veterans, nor any other targeted group under Section 51 of the Internal Revenue Code except for Summer Youth Employee applicants.

Box 14: Signature. Get the (job) applicant’s signature. If the applicant is a minor, the parent or guardian must sign. Enter date.

PART II. EMPLOYER DECLARATION & EMPLOYER INFORMATION:

Box 15: Name of Company/Firm. Enter full name of the employing firm (the firm where the employee receives wages from).

Box 16: Employment-Start Date. Enter the date the employee began or will begin work for the employing firm.

Box 17: Position/Job Title. Enter the position or job title the employee will hold/was offered employment under.

Box 18: Starting Wage. Enter the wage or salary which the employee will be paid/was hired under. If not known, enter an estimated hourly 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 1205-0371)

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 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 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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age 1 of 3 ETA Form 9062 (Rev. Feb 2023)