U.S. Department of Labor
Employment and Training Administration

OMB Control No. 1205-0371 Expiration Date: March 31, 2023

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

State:	
Quarter Ending:	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).	
PART I. CERTIFICATION WORKLOAD	

CERTIFICATION REQUESTS (System Inputs)	

CERTIFICATION REQUESTS (System Outputs)	
A) Incomplete Requests	  B) Requests Needing Action	C) New Requests
C2) Out of State Requests	D) Total Requests to be Processed	E) Certified Requests	F) Denied Requests	G) Incomplete Requests	H) Requests Needing Action	
					F1.	F2.
F3.			
PART II. CHARACTERISTICS OF CERTIFIED INDIVIDUALS	

I) By WOTC Targeted Group 	(a) No. of CCs Resulting in Certifications	(b) No. of Certified Individuals	
J) By Occupation	(a) No. of Certified Individuals	
          J) By Occupation (Cont.)	(a) No.  Certified Individuals	
K) By Starting  Hourly Wage	(a) No. Certified   Individuals	
1.  IV-A (TANF) Recipient			           
                   Name – Code No.		         
              Name – Code No.		1.  Under Federal  Minimum Wage*		
2Ba.  Veteran Receiving  SNAP Benefits (V)			
1.  Management Occupations – 11		
12.  Protective Services – 33		
2.  At  Federal 
   Minimum Wage		
2Bb.   Disabled Veteran (DV)			2.  Business & Financial Operations – 13		

13.  Food Preparation & Serving – 35		
3.  $7.25 - $9.99		

2Bc.   DV  Unemployed  for  6        mos					14.  Building & Grounds Cleaning & Maintenance – 37		

4.  $10.00 -$14.99		
2Bd.  V  Unemployed for 4  weeks			
3.  Computer & Mathematical – 15		
15.  Personal Care & Service - 39		5.  $15.00 -$19.99		
2Be. V  Unemployed for 6  mos			
4.  Architecture & Engineering – 17		
16.  Sales & Related Occupations – 41		6.  $20.00 - more 		
3.   Ex-Felon			
5.  Life, Physical & Social Sciences – 19		17.  Office/Administrative Support – 43		7. TOTAL (For Qtr)		
4.   Summer Youth Employee			
6.  Community & Social Services – 21		
18.  Farming, Fishing & Forestry – 45				

5.   Designated Community Resident			
7.  Legal Occupations – 23		
19.  Construction & Extraction – 47			
6a.   Voc. Rehab (VR)  Referral			
8.  Education, Training, & Library – 25		 20.   Installation/Maintenance /   Repair - 49				
6b.  Ticket Holder  (Ticket to Work)			9.  Arts, Design, Entertainment, Sports / Media Occupations – 27		

21.  Production Occupations – 51				
7.   SNAP Recipient			
10.  Healthcare Practitioner & Technical – 29		22.  Transportation & Material Moving Production Occupations – 53				
8.  SSI  Recipient			
11.  Healthcare Support Occupations – 31		23.  Military Specific Occupations – 55				
9.  Long-Term TANF Recipient					

 24.  TOTAL (For Qtr)				
10.  LTUR									
11.   TOTAL (For Qtr)								
12.  TOTAL (YTD)								
25.  Name and Title of Certifying Official:		26.  Signature:		27.  Date:		

Instructions for Preparing “Certification Workload and Characteristics of Certified Individuals,” ETA Form 9058, Report 1 – Work Opportunity Tax Credit
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. SWAs will report on two new metrics in the EBSS tax credit reporting system:     1) Out-of-state certification requests received during the reporting period (quarter); and                                2) Reason for issuing Denial notifications.  See Part I. Certification Workload, Item C, and Item F.

Background. The purpose of ETA Form 9058 is to provide SWAs with a standardized e- reporting 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 certification request (IRS Form 8850) received and its subsequent outcome (issuance of a 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).

INSTRUCTIONS FOR COMPLETING THIS FORM:

State. Enter the name of the state of the state workforce agency (SWA) submitting WOTC Report – 1, ETA Form 9058.

Quarter Ending. Enter ending date of the fiscal year reporting quarter for the applicable program data (i.e. QE 6/30/22).

Part I. “Certification Workload.” SWAs must identify the reporting status for each certification request (IRS Form 8850) included in the SWA’s total workload. This includes any requests (IRS Form 8850s) that the SWA interacted with during the applicable quarter ending.  Use the reporting status options for requests, as defined         below:

(A)	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 initial review) was taken. Note: This value is auto-populated with the value entered for Part I, Item (G) of the previous quarter ending’s report on ETA Form 9058.

(B)	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 period, but for which no review nor eligibility determination was rendered. Note: This total is auto-populated with the value entered for Part I, Item (B) of the previous quarter ending’s report on ETA Form 9058.

(C)	Number of New Requests. Enter the total number of new requests (IRS Form 8850s) received by the SWA during the current reporting quarter.  Note: Some SWAs may receive targeted group eligibility verification requests from other SWAs for individuals who reside (and possibly receive public welfare benefits) in their state, although the employer’s business (per IRS Form 8850) is located in another state.  These requests are referred to as “Out of State” (OOS) certification requests. SWAs should record the number of “out-of-state” certification requests received in Part I, Item (C2).  It is Important for SWAs to report all certification requests (IRS Form 8850s) received. Therefore, any requests that were received outside of the current  reporting quarter, which have not been previously recorded/ reported on a prior ETA Form 9058, should be included in the count for ‘Number of New Requests’ for the applicable quarter ending report for when the certification request is initially reviewed by the SWA. This total (new requests and previously uncounted requests) should be entered into Part I, Item (C) of ETA Form 9058. 
(D)	Total Requests to be Processed. Enter the sum of Items (A) + (B) + (C). This total represents the number of requests (IRS Form 8850s) which are available to be processed as of the quarter ending date. Note: This total is auto-tabulated based on the completion formula: Item (A +B + C) = Item D.   This value is to be entered under Part I, Item (D) of ETA Form 9058. 
(E)	Number of Requests Certified. Enter the total number of Employer Certifications (ETA Form 9063) issued by the SWA during the current report period.  Note: This value must match the value entered for Part II, Items I)11, J)24, and K)7.  

(A)	Number of Requests Denied. Enter the total number of requests (IRS Form 8850s) Denied by the SWA during the current report period. Provide the number of Denials for the F1, F2, and F3 categories defined below. (F)	Note: A Denial is a request (IRS Form 8850) determined to be ineligible by the SWA.  

	F1.  Enter the total number of Denials issued due to “failure to meet IRS Form 8850 timely-filing requirement.”

	F2.  Enter the total number of Denials issued due to “applicant does not meet targeted group(s) eligibility requirements.”

	F3. Enter the total number of Denials issued due to “ineligible rehires” (applicant previously worked for the employer seeking WOTC certification.

(A)	Number of Requests Incomplete. Enter the total number of requests (IRS Form 8850s) received and reviewed by the SWA during the current report period, but for which the SWA could neither certify nor deny by the end of the report period, due to such things as, but not limited to: missing supporting documentation (for which the SWA has made a formal request to the employer to obtain); missing or incomplete ETA Form 9061/9062; SWA processing delays due to automated system malfunctions, etc. (G)	Note: This value will auto-populate as the value entered in Part I, Item (A) of the subsequent quarter ending report, ETA  Form 9058.
(H)    Number of Requests Needing Action. Enter the number of requests (IRS Form 8850s) received by the SWA during the current report period, but for which no review and/or processing action has yet been taken to determine applicant eligibility.  This total represents the SWA’s existing “backlog” of pending requests and is auto-tabulated based on the following completion formula: Item H = Item D – (Item E + F + G). Note: This value will auto-populate as the value entered in Part I, Item (B) of the subsequent quarter ending report, ETA Form 9058.   

Part I. Completion Formulas:

Item (A +B + C) = Item D; same as: Items (A+B+C) = Item D
 
Item D – (E + F + G) = Item H; same as:  Items (D-E-F-G) = Item H

Part II. "Characteristics of Certified Individuals."  SWAs must identify the individual characteristics (of the new hire/ applicant) for each Certification issued by the SWA during the current report period. Note: Part II is divided into three subsections:  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 targeted group.  Section (J) reflects the number of requests (IRS Form 8850s) certified by the SWA during the current report period by (applicant) occupation.  Section (K) reflects the number of requests (IRS Form 8850s) certified by the SWA during the current report period by (applicant) starting hourly wage.

Section (I).

Section I, Column (a). Enter the total number of Certifications issued by the SWA, by targeted 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 Certifications issued by the SWA, by target ed group, during the current report period.
Section I, Line #1. Enter the total number of Certifications issued by the SWA during the current report period, for the Qualified IV-A (TANF) Recipients.
Section I, Line #2Ba. Enter the total number of Certifications issued by the SWA during the current report period, for Veterans receiving SNAP benefits.

Section I, Line #2Bb. Enter the total number of 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 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 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 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 Certifications issued by the SWA during the current report period for Ex-felons.
Section I, Line #4. Enter the total number of Certifications issued by the SWA during the current report period for Summer Youth Employees.
Section I, Line #5. Enter the total number of Certifications issued by the SWA during the current report period for Designated Community Residents (DCRs).  
Section I, Line #6a. Enter the total number of Certifications issued by the SWA during the current report period for Vocational Rehabilitation (VR) Referrals.

Section I, Line #6b. Enter the total number of Certifications issued by the SWA during the current report period for “Ticket Holders” (authorized under the Social Security Administration’s ‘Ticket to Work’ Program).

Section I, Line #7. Enter the total number of Certifications issued by the SWA during the current report period for SNAP (formerly known as  Food Stamps) recipients.
Section I, Line #8. Enter the total number of Certifications issued by the SWA during the current report period, for SSI recipients.
Section I, Line #9. Enter the total number of Certifications issued by the SWA during the current report period for Long-term Family Assistance (TANF) Recipients.
Section I, Line #10. Enter the total number of 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) for the current reporting quarter as TOTAL (For Qtr.) Note: The quarterly totals for Column I. “By WOTC Targeted Group” (Line#11); Column J. “By Occupation” (Line#27); and Column K. “B y S t a r t i n g H our l y W a ge” (Li ne#7 ), must all equal the same value. Note: For the first quarter ending report (ETA Form 9058) of the federal fiscal year (October 1 - December 31), the values for 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 fiscal Year-to-Date (YTD) totals of columns (a) and (b). R em i n d er: For the first quarterly report of the fiscal year (October 1- December 31), the totals of Section I, Line #11 and Line #12 should be the same value.

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, Columns (a) & (b), Line # 11.
The occupational data reported in Section J, Boxes 1-23, derive from the job titles reported on ETA Forms 9061//   9062. To prepare this report, SWAs must use the O*NET job families of occupations (standard occupation classifications) and their two-digit corresponding codes, as illustrated in the following table.

O*NET SOC JOB FAMILIES
	
OCCUPATION NAME                               CODE	

Management Occupations	
11	

Business & Financial Operations	
13	

Computer & Mathematical Occupations	
15	

Architecture & Engineering	
17	

Life, Physical & Social Sciences	
19	

Community & Social Services	
21	

Legal Occupations	
23	

Education, Training, & Library	
25	

Arts, Design, Entertainment, Sports and Media Occupations	
27	

Healthcare Practitioner & Technical	
29	

Healthcare Support Occupations	
31	

Protective Service Occupations	
33	

Food Preparation &  Serving Related	
35	

Bldg. & Grounds Cleaning & Maintenance	
37	

Personal Care & Service 	
39	

Sales & Related Occupations	
41	

Office & Administrative Support	
43	

Farming, Fishing, Forestry  	
45	

Construction & Extraction	
47	

Installation, Maintenance  & Repair	
49	

Production Occupations	
51	

Transportation & Material    Moving	
53	

Military Specific  Occupations	
55	

Section K.

Section K, Column (a). Enter the total number of Certifications issued by the SWA during the current report period, “By Starting Hourly Wage.” Note: The TOTAL (For Qtr) for Section K, Column (a),  Line #6, is the sum for that quarter, and must be equal to the total for Section I, Column (b), Line #11, “Number of Certified Individuals.”  *Federal Minimum Wage information is located at https://www.dol.gov/general/topic/wages/minimumwage.

 Convert annual earnings to hourly wages as follows:

Unit of Time	
Calculated Hourly Wage	
Day	Amount divided by 8	
W eek	Amount divided by 40	
Month	Amount divided by 172	

24.	Name and Title of Certifying Official. Enter the name and title of the authorized signatory official.
25.	Signature. Enter the signature of the authorized signatory official.
26.	Date.  Enter the date of signature.