icf-acc.pdf

ETA Advisory File Text

1 ETA Form 9061 Rev. July 2013 Individual Characteristics Form ICF 1. Control No. For Agency use only APPLICANT INFORMATION See instructions on reverse 2. Date Received For Agency Use only EMPLOYER INFORMATION 3. Employer Name 4. Employer Address and Telephone 5. Employe r Federal I D Number EIN APPLICANT INFORMATION 6. Applicant Name Last First MI 7. Social Security Number 8. Have you worked for this employer before Yes No If Y ES enter last date of employment APPLICANT CHARACTERISTICS FOR WOTC TARGET GROUP CERTIFICATION 9. Employment Start Date 10. Starting Wage 11 . Position 12. Are you at least age 16 but under age 40 Yes No If YES enter your date of birth 13. Are you a Veteran of the U. S. Armed Forces Yes No If N O go to Box 14. If YES are you a member of a family that received Supplemental Nutrition Assistance Program SNAP benefits Food Stamps for at least 3 months during the 1 5 months before you were hired Yes No If Y ES enter name o f primary recipient and city and state where benefits were received . OR are you a veteran entitled to compensation for a service -connected disability Yes No If Y ES were you discharged or released from active duty within a year before you were hired Yes No OR were you unemployed for a combined period of at least 6 months whether or not consecutive during t he year before you were hired Yes No 14. Are you a member of a family that received Supplemental Nutrition Assistance Program SNAP formerly Food Stamps benefits for the 6 months before you were h ired Yes No OR received SNAP benefits for at least a 3 -month period within the last 5 months But you are no longer receiving them Yes No If YES to either question enter name of primary recipient and city and state where benefits were received . 15. Were you referred to an employer by a Vocational Rehabilitation Agency approve d by a State Yes No OR by an Employment Network under the Ticket to W ork Program Yes No OR by the Department of Veterans Affairs Yes No U.S . Department Labor Employm ent and Training Administration OMB No. 1205 -0371 Expiration Date June 30 2015 Work Opportunity Tax Credit 2 ETA Form 9061 Rev. July 2013 16. Are you a member of a family that received TANF assistance for at least the last 18 months before you were hired Yes No OR are you a member of a family that rec eived TANF benefits for any 18 months beginning after August 5 1997 an d the earliest 18 -month period beginning after August 5 1997 ended within 2 years before you were hired Yes No OR did your family stop being eligible for TANF assistance within 2 years befo re you were hired because a Federal or state law limited the maximum time those payments co uld be made Yes No If NO are you a member of a family that received TANF assistance for any 9 months during the 18 -month period before you were hired Yes No If Y ES to any question enter name of primary recipient and the city and state where benefits were received . 17. Were you convicted of a felony or released from prison after a felony conviction during the year before you were hired Yes No If YES enter date of conviction and date of release . Was this a Federal or a State conviction Check one 18. Do you live in a Rur al Renewal County or Empowerment Zone Yes No 19. Do you live in an Empowerment Zone and are at least age 16 but not yet 18 on your hiring date Yes No 20 . Did you receive Supplemental Security Income SSI benefits for any month ending within 60 days before you were hired Yes No 21. Are you a veteran unemployed for a combined period of at least 6 months whether or not consecutive during the year before you were hired Yes No 22. Are you a veteran unemployed for a combined period of at least 4 weeks but less than 6 months whether or not consecutive during the year before you were hired Yes No 23. Sources used to document eligibility Employers Consultants List all documentation provided or forthcoming. SWAs List all documentation used in determining target group eligibility and enter your initial s and date when the determination was made . I certify that this information is true and correct to the best of my knowl edge. I understand that the information above may be subject to verification. 24 a . Signature See instructions in Box 2 4. b for who signs this signature block 24. b Signatory Options Indicate with a mark who signed this form Employer Consultant SWA Participating Agency Applicant or Parent Guardian if applicant is a minor 25. Date 3 ETA Form 9061 Rev. July 2013 INSTRUCTIONS FOR COMPLETING THE INDIVIDUAL CHARACTERISTICS FORM ICF ETA 9061. This form is used together with IRS Form 8850 to help state workforce agencies SWAs determine eligibility for the Work Opportunity Tax Credit WOTC Program . The form may be completed on behalf of the applicant by 1 the employer or employer representative the SWA a participating agency or 2 the applicant directly if a minor the parent or guardian must sign the form and signed Box 24a. by the individual completing the form. This form is required to be used without modification by all employers or their representatives seeking WOTC certif ication . Every certification request must include an IRS Form 8850 and an ETA Form 9061 or 9062 if a Conditional Certification was issued to the individual pre -certifying the new hire as eligible under the requested tar get group. Boxes 1 and 2. SWA. For agency use only. Boxes 3 -5. Employer Information. Enter the name address including ZIP code telephone number and employer Federal ID number EIN of the employer requesting the certification for the WOTC. Do not enter information pertaining to th e employer s representative if any. Boxes 6 -11. Applicant Information. Enter the applicant s name and social security number as they appear on the applicant s social security card. In Box 8 indicate whether the applicant previously worked for the empl oyer and if Yes enter the last date or approximate last date of employment . This information will help the 48 -hour reviewer to early in the verification process eliminate requests for former employees and to issue denial s to these type of requests or certifications in the case of qualifying rehire s during valid breaks in employment see pages III -12 and III -13 Nov. 2002 Third Ed. ETA Handbook 408 during the first year of employment . Boxes 12 -22. Applicant Characteristics. Read question s carefully answer each question and provide additional information where requested. On January 2 2013 President Obama signed into law the American Taxpayer Relief Act of 201 2 retroactively authorizing the Empowerment Zones EZs and WOTC non -veteran gr oups from December 31 2011 through December 31 2013. This Act also authorized continuation of the VOW Act of 2011 expanded veterans and provisions through December 31 2013. Form Updates. Empowerment Zones was added to Box 18 to capture data for D esignated Community Residents who must reside in a Rural Renewal County or EZ to be determined eligible for WOTC certification . A new Box 19 was added to this form to capture information on the Summer Youth group activated when the EZs were reauthorized. Members of the Summer Youth group must reside in an EZ to be determined eligible for WOTC certification. Boxes 19-21 were renumbered and are now Boxes 20 - 22. Box 22 below became Box 23 Sources to Document Eligibility . Box 23 Sources to Document Eligibility . The applicant or employer is requested to provide documentary evidence to substantiate the YES answers in Boxes 12 through 22. List or describe the documentary evidence that is attached to the ICF or that will be provided to the SWA . Indicate in parentheses next to eac h document listed whether it is attached A or forthcoming F . Some examples of acceptable documentary evidence are provided below. A letter from the agency that administers a relevant program may be furnished specifically add ressing the question to which the applicant answered YES. For example if an applicant answers YES to either question in Box 14 and enters the name of the pri mary recipient and the city and state in which the benefits were received the applicant could provide a letter from the appropriate SNAP formerly Foo d Stamp agency stating to whom SNAP benefits were paid the months for which they were paid and the names of the individuals included on the grant for each month. SWAs will use this box to document t he sources u sed when verifying target group eligibility followed by their initials and the date the determination was completed. Examples of Documentary Evidence and Collateral Contacts. Employers Consultants You may c heck with your SWA to find out what other sources you can use to prove target group eligibility . You are encouraged to provide copies of documentation or names of collateral contacts for each question for which you answered YES . QUESTION 12 2 Birth Certificate Driver s License Schoo l I.D. Card 1 Work Permit 1 Federal State Local Gov t I.D. 1 Copy of Hospital Record of Birth QUESTION 1 3 DD -214 or Discharge Papers Reserve Unit Contacts or Letters of Separation Letter issued only by the Department of Veterans Affairs VA on VA Let terhead or bearing the Agency Stamp with signature certifying Veteran status or that the Veteran has a service -connected disability. QUESTION S 14 16 TANF SNAP Food Stamp Benefit History Signed statement from Authorized Individual w ith a specific description of the months benefits that were received Case number identifier QUESTION 15 Voc ational Rehabilitation Agency Contact Veterans Administration for Disabled Veterans Signed Letter of Separation or related document from authorized Individual on DVA letter head or agency stamp with specific description of months benefits were r eceived . For SWAs To determine Ticket Holder TH eligibility Fax page 1 of Form 8850 to MAXIMUS at 703 -683 -1051 t o verify if applicant 1 is a TH and 2 has an I ndivi dual Work Plan from an Employment Network . QUESTION 17 Parole Officer s Name or Statement Correction Institution Records Court Records Extracts QUESTION S 18 19 To determine if a Designated C ommunity Resident DCR lives in a Rural Renewal County vis it the site www.usps.com . Click on Find Zip Code Enter Submit Address Zip C ode Click on Mailing Industry Information Download and Print the Information then compare the county of the address to the list in the Instructions to IRS Form 8850 . To determine if the DCR or a Summer Youth lives in a n Empowerment Zone check the Instructions to IRS Form 8850 or visit the U .S. Department of Housing and Urban Development s locator at http egis.hud.gov ezrclocator . 4 ETA Form 9061 Rev. July 2013 QUESTION 20 SSI Record or Authorization SSI Contact Evidence of SSI Benefits QUESTIONS 21 22 Unemployment Insurance UI Claims Records UI Wage Records Box 24 a . Signature. The person wh o completes the form signs the signature block . Box 24 b . Signat ory Options. Qualified individuals entities which can sign the form instead of the applicant a Employer b Consultant c SWA staff d Participating A gency staff e Applicant or f Parent or guardian If applicant is a minor the parent or guardian must sign . Box 25. Date . Enter the month day and year when the form was completed. Person s are not required to respond to this collection of information unless it display s a currently valid OMB Control Number. Respondent s obligation to reply to these questions is required to obtain and retain benefits per law 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 this burden estimate or any other aspect of this collect ion of information including suggestions for reducing 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 Control No. 1 205 -0371 . Cut along dotted line and k eep in your files TO THE JOB APPLICANT OR EMPLOYEE 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 th is program. The information you have provided 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. 1. Where a Federal State Local Gov t. School I.D. Card or Work Permit does not contain ag e or birth date another valid document must be obtained to verify an individual s age. 2. ESPL No. 05 -98 dated 3 18 98 officially rescinded the authority to use Form I -9 as proof of age and residence. Therefore the I -9 is no t a valid piece of do cumentary evidence since May 1998.