TEGL30-11aC.pdf

ETA Advisory File Text

1 ETA Form 9061 Rev. February 2012 I ndividual Characteristics Form ICF Work Opportunity Tax Credit 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. Employer Federal ID Number EIN A PPLICANT INFORMATION 6. A pplicant Name Last First MI 7. S ocial Security Number 8. Have you worked for this employer be fore Y es No If YES e nter l ast d ate of em ployment A PPLICANT CHARACTERISTICS FOR WOTC TARGET GROUP CERTIFICATION 9. E mployment Start Date 10. S tarting Wage 11. Position 12. A re you at least age 16 but under age 40 Y es No If YES enter your da te of birth 13. A re you a Vete ran of the U.S. Armed Forces Y es N o If NO go to B ox 14. If YES are you a member of a family that r eceived S upplemental Nutrition A ssi stance P rogram SNAP be nefits F ood Stamps f or at least 3 m onths during the 15 m onths b efore y ou were hired Y es No If YES enter name of prim ary r ecipient and ci ty and st ate where benefits were received . OR are you a vet eran en titled to compensation for a service-c onnected disability Y es No If YES were you discharged or released from active duty within a year before you w ere hi red Y es No OR wer e you unemployed for a combined period of at least 6 months whether or not c onsecutive d uring th e y ear before you were hired Y es No 14. A re you a member of a family that received S upplemental Nutrition Assistance Program SNAP be nefits Food Stamps f or the 6 months before you wer e hired Y es No OR r eceived Food Stamps for at least a 3-m onth period wi thin the last 5 m onths Bu t y ou are no longer receiving them Y es No If YES t o either question e nter name of prim ary recipient And ci ty and stat e w here benefits were received . 15 . Were you referred to an employer by a Voc ati onal Reh abilitation Age ncy ap proved by a St ate Y es No OR by an Employment Network under t he Ticket to Work Program Y es No OR by the Department of Veterans Affairs Y es No U.S. Department Labor Employment and Training Administration OMB No. 1205-0371 Expiration Date April 30 2012 SA MPLE ATTACHMENT C 2 ETA Form 9061 Rev. February 2012 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 received TANF benefits for any 18 months beginning after August 5 1997 and 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 before you were hired because a Federal or state law limited the maximum time those payments could 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 YES 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 Empowerment Zone or Rural Renewal Community Yes No 19. Did you receive Supplemental Security Income SSI benefits for any month ending within 60 days before you were hired Yes No 20. Are you an Unemployed Veteran who served on active duty other than active duty for training in the Armed Forces of the United States for a period of more than 180 days Yes No OR were you discharged or released from active duty in the Armed Forces for a service-disconnected disability Yes No If YES were you discharged or released from active duty at any time during the 5-year ending on the hiring date Yes No If YES did you receive unemployment compensation for not less than four weeks during the One-year period ending on the hiring date Yes No 21. Are you a member of the Disconnected Youth group because you are at least age 16 but under age 25 and Yes No Not regularly attending any secondary technical or post-secondary school during the 6-month period before your hiring date and Yes No Not regularly employed other than occasionally during that 6-month period and Yes No Not employable for lacking a sufficient number of basic skills Yes No 20. 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 21. 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 22. 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 initials and date when determination was made. I certify that this information is true and correct to the best of my knowledge. I understand that the information above may be subject to verification. 23 a . Signature See instructions for Box 21 for who signs this signature block 23. b Indicate with a who signed the form Employer Consultant SWA Participating Agency Applicant or Parent Guardian if applicant is a minor 24. Date SAMPLE 3 ETA Form 9061 Rev. February 2012 IN STRUCTIONS 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 by the individual completing the form. This form is required to be used without modification by all employers or their representatives seeking WOTC certification. 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 tart 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 the 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 employer 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 denials to these type of requests or certifications in the case of qualifying rehires 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 12-21. Applicant Characteristics. Read questions carefully answer each question and provide additional information where requested. Box 22 Sources to Document Eligibility. The applicant or employer is requested to provide documentary evidence to substantiate the YES answers in Boxes 12 through 21 . 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 each 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 addressing 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 primary recipient and the city and state in which the benefits were received the applicant could provide a letter from the appropriate Food Stamp agency stating to whom Food Stamp 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 the sources used 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 check 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 123 Birth Certificate Driver s License School I.D. Card1 Work Permit1 Federal State Local Gov t I.D.1 Copy of Hospital Record of Birth QUESTION 13 DD-214 or Discharge Papers Reserve Unit Contacts Letter Issued Only by the Department of Veterans Affairs VA on D VA Letterhead Certifying the Veteran Has a Service-Connected D isability. QUESTIONS 14 16 TANF SNAP Food Stamp Benefit History Signed Statement from Authorized Individual with Specific Description of the Months Benefits Were Received Case Number Identifier QUESTION 15 Vocational Rehabilitation Agency Contact Veterans Administration for Disabled Veterans Signed Letter from Authorized Individual in DVA Letter Head w ith Specific Description of Months Benefits Rec eived For SWAs To determine Ticket Holder TH eligibility Fax page 1 of Form 8850 to MAXIMUS at 703-683-1051 to verify if applicant 1 is a TH and 2 has an Individual Work Plan from an Employment Network. QUESTION 17 Parole Officer s Name or Statement Correction Institution Records Court Records Extracts QUESTION 18 Driver s License Work Permit Utility Bills W-4 Lease Papers Library Card2 Voter Registration Card SNAP Food Stamp Award Letter Selective Service Registration Card To determine if a Designated Community Resident lives in a RRC visit the site www.usps.com. Click on Find Zip Code Enter Submit Address Zip Code Click on Mailing Industry Information Download and Print the Information then compare the county of the address to the list in the Jan. 2012 Instructions to IRS 8850. QUESTION 19 SSI Record or Authorization SSI Contact Evidence of SSI Benefits Notes. 1. W here a Federal State Local Gov t. School I.D. Card or W ork Permit do es not contain age or birth date another valid document must be obtained to verify an individual s age. 2. W here a Library Card does not contain the holder s address another document issued i showing the jurisdiction where the RRC is located must be obtained showing the holder s address. 3. 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 longer a valid piece of documentary evidence. SAMPLE 4 ETA Form 9061 Rev. February 2012 QUESTION S 20 and 21 Unemployment Insurance UI Claims Records UI Wage Records Box 23. Signature. The person who completes the form signs the signature block. Options a Employer or Authorized Representative b SWA staff c Participating Agency staff or d Applicant If applicant is a minor the parent or guardian must sign . Box 24. Date. Enter the month day and year when the form was completed. 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 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 collection 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. 1205-0371 . ...... Cut along dotted line and keep 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 this 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. SAMPLE Individual Characteristics Form ICF U.S. Department of Labor Work Opportunity Tax Credit Employment and Training Administration 1. Numero de Control Para uso de la Agencia solamente SPANISH VERSION Informaci n del Solicitante Esta forma en Espa ol NO es la oficial. sela solo para familiarizarse con las preguntas. Luego conteste firme y feche la forma en Ingles OMB No. 1205-0371 Fecha de Expiraci n April 30 2012 2. Fecha en que la informaci n fue recibida. INFORMACION DEL PATRONO 3. Nombre del Patrono 4. Direcci n y Tel fono del Patrono 5. Numero Federal ID EIN Patrono INFORMACION DEL SOLICITANTE 6. Nombre del Solicitante Apellido Primer Inicial 7. Numero Seguro Social 8. Ha trabajado para este patrono antes Si No Si contesta Si provea la fecha de su ultimo empleo REQUISITOS QUE HACEN AL SOLICITANTE ELEGIBLE PARA CERTIFICACION BAJO WOTC 9. Fecha en que comenz a Trabajar 10. Salario 11. Posicion Titulo 12. Tiene Ud. por lo menos 16 a os pero es menor de 40 Si No Si contesta SI provea su fecha de nacimiento 13. Es Ud. un Veterano de las Fuerzas Armadas de los Estados Unidos de Am rica USA Si No Si contesta NO llene el encasillado 14. Si contesta SI es Ud. miembro de una familia que recibi beneficios de Pan y Trabajo Aplica a Puerto Rico solamente o que recibi Cupones para Alimentos Programa Suplementario de Asistencia Nutricional SNAP o sea Food Stamps por lo menos por 3 mese durante los 15 meses antes de ser empleado Si No Si contesta SI provea nombre del beneficiario principal y el nombre de la ciudad estado donde recibi los beneficios O es Ud. un Veterano con derecho a beneficios por Incapacidad F sica relacionados con su servicio militar Si No Si contesta SI fue Ud. dado de baja del servicio activo militar un a o antes de ser empleado Si No O estuvo Ud. desempleado por un periodo de por lo menos 6 meses durante el a o antes de ser empleado Si No 14. Es Ud. miembro de una familia que recibi beneficios bajo el Programa Pan y Trabajo en P.R. o beneficios bajo el Programa Suplementario de Asistencia Nutricional SNAP Cupones de Alimento o sea Food Stamps durante los 6 meses antes de ser empleado Si No O recibi beneficios bajo el programan SNAP Cupones de Alimentos por un periodo de 3 meses durante los 5 meses antes de ser empleado pero ya no recibe estos beneficios Si No Si contesta SI a cualquiera de las preguntas provea el nombre del beneficiario principal y la ciudad estado donde los beneficios fueron recibidos . Ciudad Estado Pagina 1 de 2 ETA Forma 9061 Rev. Aug. 2009 SAMPLE ATTACHMENT C Individual Characteristics Form ICF U.S. Department of Labor Work Opportunity Tax Credit Employment and Training Administration Continuacion SPANISH VERSION 15. Fue Ud. referido a un patrono por una Agencia de Rehabilitaci n Vocacional Estatal Si No O por un Employment Network bajo el programa Ticket to Work del Seguro Social Si No O por el Departamento de Asuntos del Veterano Si No 16. Es Ud. miembro de una familla que recibi asistencia TANF por lo menos en los ltimos 18 meses antes de ser empleado Si No O es Ud. miembro de una familia que recibi asistencia TANF por cualquier periodo de 18 meses comenzando estos beneficios despu s del 5 de agosto de 1997 y el ultimo periodo de 18 meses que comenz despu s del 5 de agosto de1997 termino 2 a os antes de Ud. ser empelado Si No O su familia no cualific para asistencia TANF durante 2 a os antes de ser empleado pero una ley Federal o estatal limito el per odo m ximo para Ud. recibir esos pagos Si No Si contesta No es Ud. miembro de una familia que recibi asistencia TANF por 9 meses durante los 18 meses antes de ser empleado Si No Si contesta Si provea el nombre del beneficiario principal Nombre y el nombre de la ciudad estado donde los beneficios fueron recibidos . Ciudad Estado 17. Fue Ud. convicto por un delito o violaci n a la ley y puesto en libertad despu s de la encarcelaci n durante el a o antes de Ud. ser empleado Si No Si contesta SI provea la fecha de apresamiento o encarcelaci n y la fecha de excarcelaci n o cuando fue puesto en libertad . Indique con un si esta fue una convicci n Federal o Estatal . 18. Vive Ud. en un Empowerment Zone o Renewal Community Si No O en un Rural Renewal County RRC o Condado Si No Si contesta SI provea el nombre del RRC . Nombre del RRC 19. Recibi Ud. beneficios de Supplemental Security Income SSI por cualquier mes que termino 60 d as antes de ser empleado Si No 20. Es Ud. un Veterano Desempleado que estuvo en servicio activo militar excepto servicio activo para adiestramiento en las Fuerzas Armadas de los Estados Unidos de America EUA por un periodo mayor de 180 d as Si No O fue dado de baja del servicio activo militar de las Fuerzas Armadas de los EUA debido a una Incapacidad F sica como resultado de su servicio militar Si No Si contesto SI fue Ud. dado de baja del servicio activo militar de las Fuerzas Armadas de los EUA en cualquier fecha durante un periodo de 5 a os antes de ser empleado Si No Si contest SI recibi Ud. beneficios por desempleo UI por un periodo no menor de 4 semanas durante el a o inmediatamente antes de ser empleado Si No 21. Es Ud. miembro del grupo de J venes Desconectados Disconnected Youth porque tiene por lo menos 16 a os de edad pero menos de 25 Si No Si contestaste SI no has ido regularmente a ninguna escuela secundaria t cnica o post-secundaria durante un periodo de 6-meses antes de la fecha en que fuiste empleado Si No Si contestaste SI no has sido empleado regularmente excepto ocasionalmente durante dicho periodo de 6 meses Y Si No Si contestaste SI no eres candidato para ser empleado debido a que no tienes las destrezas laborables necesarias Si No 20. Es Ud. un Veterano y ha estado desempleado por un per odo combinado de 6 meses consecutivos o no SAMPLE durante el a o inmediatamente antes de ser empleado Si No 21. Es Ud. un Veterano y ha estado desempleado por un periodo combinado de por lo menos 4 semanas pero menos de 6 meses durante el a o inmediatamente antes de ser empleado Si No Pagina 2 de 2 Rev. Aug. 2009 20. Evidencia para documentar elegibilidad Patronos Favor nombrar los documentos que envi con esta forma o los que enviara luego. SWAs indiquen los documentos que usaron para determinar si el individuo es elegible o no. Entre sus iniciales y la fecha en que completo esta determinaci n Pregunta 13 Carta Recibida de la Administraci n de Veteranos VA Con Informaci n Sobre Incapacidad F sica Ej. Compensaci n o Beneficios Debido Al Servicio Militar. Debe tener el membrete oficial de VA y estar debidamente firmada por personal oficial. Patrono o Veterano Documentaci n necesaria para corroborar su estado como Veterano Desempleado durante el periodo requerido Preguntas 20 y 21. Expedientes de Reclamo Beneficios por Desempleo UI Expedientes de Salario Unidad de Beneficios por Desempleo UI Certifico que esta informaci n es ver dica y correcta y entiendo que dicha informaci n esta sujeta a verificaci n. 21. Firma Vea instrucciones en Ingles para saber quien firma este encasillado 21. b Indique con un quien firmo la forma Patrono Representante SW A Agencia Participante Solicitante o Padre Guardi n si el solicitante es menor de edad 22. Fecha Pagina 3 de 3 ETA Form 9061 Rev. February 2012 SAMPLE ETA Form 9062 Rev. February 2012 Conditional Certification Work Opportunity Tax Credit EMPLOYERS This form must be accompanied by IRS Form 8850. If you do not have IRS Form 8850 call 202-693-2786 for a copy or download it from 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 W orkforce Agency SW A within 28 days after the new hire s employment-start date. IRS granted a Relief Filing Period that applies to veterans applications. See additional information in the Note to Employer section below. 1. INITIATING AGENCY CODE For Agency Use Only CODE 2. CONTROL NO. For Agency Use Only One Participating Agency SWA 3. TYPE OF CONDITIONAL CERTICATION a. Original For Summer Youth ONLY One a. Original b. Revalidation 4. FOR EX-FELON TARGET GROUP ONLY a. Conviction Date c. Correction s ID No. b. Release Date 5. DATE COMPLETED MM DD YY 6. STATE WORKFORCE AGENCY s NAME ADDRESS 7. SIGNATURE Authorized Official 8. TELEPHONE No. PART I. APPLICANT S INFORMATION AND CONDITIONAL CERTIFICATION CC 9. NAME OF APPLICANT Last First Middle 10. SOCIAL SECURITY No. 11. ENTER TARGET GROUP CODE OTHER THAN Veteran 12. ADDRESS Street City State Zip Code Telephone No. 13a. VETERAN TARGET GROUP CODES One 2Ba. Qualified 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 13b. TARGET GROUP CODE Cont Unemployed Veteran Disconnected Youth 14. APPLICANT SIGNATURE NOTE TO EMPLOYER 15. The above named individual may be eligible for certification under the Work Opportunity Tax Credit. If individual is not employed before the date in the box below Mo. Day Yr. this eligibility determination is subject to review. In the event you hire this person you should request the certification necessary for you to claim a Work Opportunity Tax Credit WOTC . Simply complete and sign the Employer Declaration below submit to the SWA together with IRS Form 8850 not later than June 19 2012 for veterans that began employment for you on or after November 22 2011 and before May 22 2012. For veterans who began employment for you after May 22 2012 and before January 1 2013 submit to the SWA not later than 28 days after the applicant started work. The WOTC Employer Certification will be sent to you if all statutory requirements have been met. PART II. EMPLOYER DECLARATION I hereby declare that the above named person is or will be employed by 16. NAME OF FIRM AND ADDRESS 17. POSITON JOB TITLE 18. EMPLOYMENT-START DATE 19. STARTING WAGE per hr ATTN SWA Please send a WOTC Certification for this employee. The pre-certification is for the purpose of requesting Certification to obtain the WOTC 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. Employers are further advised that if the certification herein requested is for a member of the SUMMER YOUTH target group the tax credit for which he she may be eligible is subject to the limits described at Sec. 51 d 7 of the Internal Revenue Code. NOTE 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. 20. EMPLOYER S NAME 21. EMPLOYER S SIGNATURE 22. DATE MM DD YY U.S. Department Labor Employment and Training Administration OMB No. 1205-0371 Expiration Date April 30 2012 SAMPLE ATTACHMENT C ETA Form 9062 Rev. February 2012 CONDITIONAL CERTIFICATION CC ETA FORM 9062 . When a SWA or Participating Agency PA determines that a job-ready applicant is tentatively ELIGIBLE as a member of a target group under WOTC it shall use this required form without modification to show that an eligibility determination was made for this person. Note. The CC serves as an official record of the pre-certification alerts prospective employers to the availability of the tax credit if this veteran is hired and provides a means for employers to request a WOTC certification for this person. INSTRUCTIONS FOR COMPLETING THE CONDITIONAL CERTIFICATION FORM. Boxes 1-15 are for Participating Agency PA and SWA use only Box 1 Initiating Agency Code. If the CC was issued by a Participating Agency 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 code if available. 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 designation 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 Type of Conditional Certification. This system distinguishes between Original if the individual is being processed for the first time or Revalidation if the eligibility process was performed within the previous 12-month period e.g. 45 days for the Summer Youth target group only . Otherwise the Conditional Certification is counted as Original. Indicate with a check mark whether the eligibility determination is Original or Revalidation. Box 4 For Ex-Felon Target Group Only. For items a - c enter the corresponding information. This information will help you in verifying target group eligibility. Box 5 Date Completed. Enter the month day year in which the eligibility determination was completed. Box 6 SWA s Name and Address. If known enter or stamp the name and address including zip code of the SWA responsible for Certification requests for the employer indicated in Box 16. Leave blank if SWA s name and address is unknown. Box 7 Signature. Enter signature of the authorized conditionally-certifying official. Box 8 Telephone No. Enter corresponding SWA or PA area code telephone number and extension if available. PART I. APPLICANT S INFORMATION AND CONDITIONAL CERTIFICATION CC Box 9 Name of Individual. Enter the individual s applicant s full name i.e. last name first name and middle initial . Box 10 Social Security Number. Enter the individual s applicant s Social Security Number. Box 11 Target Group Code. Enter the code or name of the pre-certified non-veteran group. Box 12 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 13a Target Group Code. The 1996 original target group designation for a Qualified Veteran is B. To facilitate the identification of the different veteran categories created by the VOW to Hire Heroes Act of 2011 P.L. 112-56 ETA is using the same alpha- numeric designations used to collect the number of certifications issued for the amended veteran categories in ETA Form 9058 Report 1. To ensure a simple uniform and consistent certification system which can be used by the SWAs nationwide each new veteran category is preceded by B and followed by the alpha-numeric code used in ETA Form 9058. All the SWAs need to do is e nter a check mark in front of the veteran group certified. Box 13b Target Group Code Continued . Enter a check mark to indicate if individual is being pre-certified as Unemployed Veteran or Disconnected Youth meeting the requirements introduced by the Recovery Act of 2009 P.L. 111-5. Box 14 Signature. Get applicant s signature. If a minor parent or guardian must sign here. Box 15 CC Validity Period. This box is to be completed by the SWA or PA . Enter the month day year when the CC expires e.g. 45 days for Summer Youth Page 2 of 3 SAMPLE ETA Form 9062 Rev. February 2012 Part II. EMPLOYER DECLARATION Box 16 Name of Firm. Enter full name of the employing firm the firm where the employee will actually work . Box 17 Position Job Title. Enter the position or job title the employee will hold. Box 18 Employment-Start Date. Enter the date the employee began or will begin work for the employing firm. Box 19 Starting Wage. Enter the wage or salary which the employee will be paid. If not known enter an estimated wage. Box 20 Employer s Name and Signature. Enter your name as the hiring employer. Box 21 Employer s Signature. Affix your electronic or ink signature here. Box 22 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 .33 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 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. Page 3 of 3 SAMPLE Employer Certification Work Opportunity Tax Credit OPTIONAL FORMAT 1. NAME ADDRESS OF CERTIFYING AGENCY AND TELEPHONE NO. 2. CONTROL NO. For Agency Use Only 3. DATE COMPLETED 4. INITIATING AGENCY CODE For Agency Use Only PART A. EMPLOYER 5. NAME ADDRESS OF FIRM TELEPHONE NO. 6. EMPLOYER TAX EIN 7. REPRESENTATIVE S NAME TITLE ADDRESS. PART B. EMPLOYEE 8. SOCIAL SECURITY NO. 9. EMPLOYMENT START DATE Mo Day Yr. 10. NAME AND ADDRESS OF EMPLOYEE 12. VETERAN TARGET GROUP CODES those that apply 2Ba. Qualified 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 Unemployed Veteran Disconnected Youth 11. NON-VETERAN TARGET GROUP CODE AND NAME PART C. CERTIFICATION I HEREBY CERTIFY that the individual named in Part B meets the eligibility criteria of Sec. 51 of the Internal Revenue Code. 13. NAME OF CERTIFYING OFFICER Print or Type 14. SIGNATURE. Certifying Officer 15. DATE ISSUED Comments to Employers The VOW to Hire Heroes Act of 2011 P.L. 112-56 extends and amends the current veteran group creates two additional categories of unemployed veterans in Section 51 of the Internal Revenue Code and makes the WOTC available to qualified tax-exempt organizations in Section 52. The VOW Act grants the WOTC to employers that hire certain qualified veterans who begin employment on or after November 22 2011 and before January 1 2013. This Act did not extend the non-veteran WOTC categories which expired on December 31 2011. For additional information on filing certification requests to the State Workforce Agencies SWA and veterans eligibility requirements visit WOTC s national website at www.doleta.gov wotc to obtain an e-copy of TEGL No. xx-xx a brochure on WOTC and Veterans and a Fact Sheet that provides an overview of the provisions in the VOW Act. Employers are also encouraged to visit IRS s website at www.irs.gov to obtain e-copies of IRS s Notice 2012 -13 and the January 2012 IRS Form 8850 and Instructions. EMPLOYERS Before you can claim the WOTC your new hire s must work the required number of hours to meet the Minimum Employment or Retention Period. Visit IRS s website at www.irs.gov for additional information on this and other requirements. Note . More information is available in the instructions for IRS Form 8850 5884 Work Opportunity Credit for tax year 20 12. 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 Page of 1 of 2 ETA Form 9063 Rev. February 2012 U.S. Department Labor Employment and Training Administration OMB No. 1205 -0371 Expiration Date April 30 2012 SAMPLE ATTACHMENT C INSTRUCTIONS FOR COMPLETING AND ISSUING THE CERTIFICATION FORM CF ETA 9063. Documentary evidence of eligibility and or collateral contacts is required to issue a WOTC Certification. Information on the Certification substantiates the employer is entitled to claim a tax credit against the first-year wages paid to the new hire. Note SW As must inform each employer who receives a WOTC Certification of the required Minimum Employment Period as stated in the Comment Box of the Certification. However enforcement of this requirement is strictly an IRS responsibility. Boxes to be completed on the Certification Box 1 Name and Address. Identify the SW A 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 name and address including zip code. Box 6. Employer Tax EIN Number. Enter employer s taxpayer identification. 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 and initial and address including zip code and telephone number if available. Box 11. Targeted Groups. Enter SW A Code and target group name for the certified non-veteran group. Box 12. Targeted Groups. Indicate with a check mark which veteran group is being certified. Box 13. Certifying Official. Key in print full name and title of authorized certifying official. Box 14. Signature. Enter authorized certifying official s signature. Box 15. Date. Enter month day and year when the Certification is issued by the certifying official. 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 .33 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 . 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 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. Page 2 of 2 ETA Form 9063 Rev. February 2012 Page 2 of 2 ETA Form 9063 Rev. February 2012 SAMPLE Work Opportunity Tax Credit For SWAs Internal Use Only U. S. Department of Labor OMB No. 1205-0371 Employment Training Administration Expiration Date April 30 2012 1. NAME OF INDIVIDUAL 2. SOCIAL SECURITY NO. Agency Declaration of Verification Results Worksheet 3. EMPLOYER S NAME TELEPHONE NO. AND ADDRESS THE SECTION BELOW IS TO BE COMPLETED BY THE SWA CERTIFYING AGENCY ONLY. 4. CERTIFYING AGENCY Check one 5. DATE CERTIFIED CC Issued By Participating Agency or SW A SAMPLE 6. SOURCES USED TO DOCUMENT ELIGIBILITY 7. AUDIT SAMPLE RESULTS Complete ONLY if selected as part of RANDOM SAMPLE in quarterly audit a. I have reviewed contacted the source s indicated in box 6 above and have confirmed that th e certified individual is ELIGIBLE. b. I have reviewed contacted the source s indicated in box 6 above and have confirmed that the certified individual is INELIGIBLE for the following reason s c. I have not been able to establish that the certified individual is INELIGIBLE because NOTE Falsification of data on this form is a FEDERAL CRIME in violation of 18 USC 1001. Falsification of work or concealment of information is PUNI SHABLE by a FINE or IMPRISONMENT. 8. NAME AND TITLE OF REVIEWER Type or Print 9. SIGNATURE Certifying Officer 10. DATE Persons are not required to respond to this collection of information unless it displays a valid OMB Control Number. Respondent s obligation to reply to these requirements is mandatory by P.L. 104-188. Public reporting burden for this collection of information is estimated to average 1 hour 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 US. Department of Labor Division of National Programs Tools and Technical Assistance Room C-4510 W ashington 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 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. Page of 1 of 2 ETA Form 9065 Rev. February 2012 Previous versions usable Instructions for Completing the Agency Declaration of Verification Results ADVR Worksheet ETA FORM 9065. Background The Omnibus Budget Reconciliation Act of 1990 P. L. 101-508 11405 c extended indefinitely the 5 million set- aside cited below for testing whether individuals certified as members of WOTC targeted groups are eligible for certification including the use of statistical sampling techniques . As long as there is a WOTC appropriation this requirement continues in force. These provisions apply in full force to the certification process under the consolidated WOTC Program. Section 261 f 2 of the Economic Recovery Tax act of 1981 P .L. 97-34 as amended states that A 5 000 000 shall be used to test whether individuals certified as members of targeted groups under section 51of such Code Internal Revenue are eligible for such certification including the use of statistical sampling techniques and B the remainder shall be distributed under performance standards prescribed by the Secretary of Labor. Note . Verification activities require testing the validity of all Certifications issued by the SWAs including the Conditional Certifications issued by Participating Agencies PAs and other documentation which results in Certifications. Quality reviews and audits are both parts of the certification process. A General Accounting Office GAO report recommended that verification activities be done by other than the person who originally processed... the Individual Characteristics ETA Form 9061 or the Conditional Certification ETA Form 9062 forms. DEFINITIONS 1. Quality Reviews - the reviews conducted at specific points in the eligibility determination certification process of forms and other documentation including the Certification itself to ensure that the required information is complete consistent and accurately recorded. 2. Audit - the post-issuance examination of a random sample of Certifications and supporting documentation to verify the validity of the Certifications issued. INSTRUCTIONS FOR COMPLETING THE AGENCY DECLARATION OF VERIFICATION RESULTS ADVR FORM. Box 1. Name of Individual. Enter the full name last first and middle initial of the certified target group member employee. Box 2. Social Security No. Enter the employee s social security number. Box 3. Employer Name Telephone No. Address. Enter employer s name and address including zip code and telephone number. Box 4. Certifying Agency. Enter name of SWA issuing the Certification. Indicate with a check mark whether the CC was issued by a Participating Agency or a SWA. Box 5. Date Certified. Enter month day and year when the Certification was issued. Box 6. Documentary Sources. List and or describe the documentary evidence or sources of collateral contacts that are attached to the Certification request IRS 8850 and or Individual Characteristics Form. Box7. Audit Sample Results. Indicate with a check mark if individual is eligible ineligible or eligibility cannot be determined and follow the instructions below. a. If review of documentation reveals that the certified individual is eligible enter a check mark . b. If review of documentation reveals that the certified individual is ineligible explain why and for Conditional Certifications CCs prepare and send the following notices Notification of Invalidation NOI - to the applicant the SWA PA staff and employer consultant. The NOI notifies the employer consultant to whom applicant was referred that the CC ETA form 9062 is invalid because of missing or incorrect information items and that without such information a Certification cannot be issued. Notice of Revocation NOR - prepare and send to employer consultant an NOR explaining the reasons for revocation and send a copy to the Regional Office and IRS in your state since employer eligibility for the tax credit does not cease until the date that the employer is officially notified in writing that the Certification ETA Form 9063 has been invalidated thereby revoked. c. If review of documentation reveals that the SWA has not been able to establish eligibility explain the reason. Box 8. Name and Title of Reviewer. Enter full name and title of authorized staff conducting audit review. Box 9. Signature. Enter signature of authorized reviewer conducting audit. Box 10. Date. Enter month day and year when audit was conducted. Page 2 of 2 ETA Form 9065 Rev. February 2012 SAMPLE State Quarter Ending Persons are not required to respond to this collection of information unless it displays a currently valid OM B control numbe r. Respondents obligation to reply to these re porting requirements is mandatory P.L. 104-188 . Public reporting burden for this collection of information 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 collection of information including suggestions for reducing this 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 . OMB No. 1205 -0371 Expiration Date April 30 2012 PART I. CERTIFICATION WORKLOAD CERTIFICATION REQUESTS System Inputs CERTIFICATION REQUESTS System Outputs A Incomplete Requests B Requests Needing Action C New Requests D Total Requests to Be Processed E Certified Requests F Denied Re quests G Incomplete Requests H Requests Needing Action PART II. CHARACTERISTICS OF CERTIFIED INDIVIDUALS I By WOTC Target Group a No. of CCs Resulting in Certifications b No. Certified Individuals J By Occupation a No. 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 Name-Code 1. Under Federal Minimum Wage 2Ba. Veteran Receiving SNAP benefits V 1. Management Occupations 11 12. Protective Services 33 2. 7.25 - 8.25 2Bb. Disabled Veteran DV 2. Business Financial Operations 13 13. Food Preparation Serving 3 3. 8.26 8.99 2Bc. DV unemployed for 6 months 14. Bldg. Grounds Cleaning Maintenance 37 2Bd. V unemployed for 4 weeks 3. Computer Mathematical 15 15. Sales Related Occupations 41 4. 9.00 - 9.99 2Be. V unemployed for 6 months 4. Architecture Engineering 17 16. Office Administrative Support 43 5. 10.00 - Higher 3. Ex-Felon 5. Life Physical Social Sciences 19 17. Farming Fishing Forestry 45 6. TOTAL For Qtr. 4. Designated Community Resident 6. Community Social Services 21 18. Construction Extraction 47 5a. Voc. Rehab Referral 7. Legal Occupations 23 19. Installation Maintenance Repair - 49 5b. Ticket Holder 8. Education Training Library 25 20. Production Occupations 51 6. Summer Youth 9. Arts Design Entertainment Sports Media Occupations 27 21. Transportation Material Moving Production Occupations 53 6. SNAP Recipient 10. Healthcare Practitioner Technical 29 22. Military Specific Occupations 55 7. SSI Recipient 11. Healthcare Support Occupations 31 8. Unemployed veteran 9. Disconnected Youth 8. Long-term TANF Recipient 9. TOTAL For Qtr. Certification Workload and Characteristics of Certified Individuals Work Opportunity Tax Credit - Report No. 1 U.S. Department of Labor Employment and Training Administration SAMPLE ATTACHMENT C Page 1 of 5 ETA Form 9058 Rev. February 2012 10. Total TOTAL YTD 23. Name and Title of Responsible Official 24. Signature Title 25. Date Signed 26. Total For Qtr. Instructions for Preparing ETA Form 9058 Report 1 Certification Workload and Characteristics of Certified Individuals Work Opportunity Tax Credit Report REVISED INSTRUCTIONS Introduction . Part I. of this report clarifies and simplifies data reported on certifications issued and provides state workforce agencies SWAs workload during each reporting quarter. Part II. continues to collect data on selected characteristics of certified individuals. Boxes 2a through 2e were added to collect data from the expanded Veteran groups and provisions introduced by the VOW to Hire Heroes Act of 2011 P.L. 112-56 . Box 6. Summer Youth was deleted because the legislative authority for HUD s urban and USDA s rural Empowerment Zones EZs expired on December 31 2011 and the statutory definition for this group requires that the youth must reside in an EZ. Box 7 SNAP Recipient became number 6 and Boxes 7-13 were renumbered as follows Box 7. SSI Recipient Box 8. Long-Term TANF Box 9. TOTAL For QTR. and Box 10. TOTAL YTD Explanation of VOW to Hire Heroes Act of 2011 Changes . Since 1996 SWAs use the B alpha statutory classification for the Veteran group for verification of and issuing certifications to the qualified veteran group. To distinguish among the current and new veteran categories and provide the SWAs with a uniform system to report the number of certifications issued by each new group the B classification has been added and is followed by alpha-numeric identifiers for Veteran Boxes No. 2a through 2e as follows Box 2Ba. Added V after Veteran receiving SNAP benefits Box 2Bb. Added DV after Disabled Veteran Added Box 2Bc. and titled it DV unemployed for 6 months Added Box 2Bd. and titled it V unemployed for 4 weeks Added Box 2Be. and titled it V unemployed for 6 months The two W OTC ARRA target groups Unemployed Veterans and Disconnected Youth authorized by the American Recovery and Reinvestment Act P.L. 111-5 expired on December 31 2010. These target groups formerly Boxes 10 and 11 have been removed. Background . The purpose of ETA Form 9058 Updated February 2012 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 tax request IRS Form 8850 received and its subsequent outcome issuance of a tax 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 accurately evaluated 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 S tate. Enter the name of the state submitting ETA Form 9058. Q uarter Ending Period. Enter ending date of the quarter for the reported program data. Part I. Certification Workload. SW As must identify from Part I Item F on the previous reporting quarter s ETA Form 9058 the number of requests IRS Form 8850s determined to be incomplete or Needing Action as defined below A Number of Requests Incomplete. Enter the total number of requests IRS Form 8850s received by the SW A prior to the beginning of the current report period but for which no applicant eligibility determination action excluding the 48-hour review was taken. This total is to be entered into Part I Item A of ETA Form 9058. B Number of Requests Needing Action. Enter the total number of requests IRS Form 8850s received by the SW A prior to the beginning of the current report but for which no review and total is to be entered into Part I Item B of recently revised ETA Form 9058. C New Requests. Enter the total number of requests IRS Form 8850s received by the SWA during the current reporting quarter. Some states may have received requests IRS Form 8880s that were not previously recorded and or reported on any prior quarterly report ETA 9058 for various reasons. It is Important for the SWA to report all requests IRS Form 8850s received. Therefore any request received outside of the current reporting quarter which has not previously been reported should be included with the number of requests received during the current reporting period. That total should be entered as the number of New Requests . This total is to be entered into Part I Item C of ETA Form 9058. Page 2 of 5 ETA Form 9058 ETA Form 9858 Rev. February 2012 SAMPLE D Total Requests to Be Processed. Enter the sum of Items A B C. This total represents the number of requests IRS Form 8850s received by the SW A which are available to be processed. This total is to be entered under Part I Item D of ETA Form 9058. Note . A denial is a request IRS Form 8850 determined by the SWA to be ineligible for the WOTC. E Requests Certified. Enter the total number of WOTC certifications issued during the current report period. F Requests Denied. Enter the total number of requests IRS Form 8850s denied by the SWA during the current report period. Note . A denial is a request IRS Form 8850 determined by the SWA to be ineligible for the WOTC. G Number of Requests Incomplete. Enter the total number of requests IRS Form 8850s received and reviewed by the SW A but which the SW A could neither approve nor deny due to such things as but not limited to the need for additional eligibility documentation for which the SWA has made a formal request to the employer authorized tax consultant or other third party entity ETA Form 9061 not submitted etc. Note . This number will also be entered in Part 1 Item A. of the subsequent quarterly report ETA Form 9058. H Number of Requests Needing Action . Enter the number of requests IRS Form 8850s received by the SWA but for which no review and or action has yet been taken to determine applicant eligibility. Note . This value will also be entered in Part I Item B. of the subsequent quarterly report ETA Form 9058. Part I Item H is the sum of Item D minus Item E minus Item F minus Item G. Part I. Completion Formula A B C D and D E F G H Same as Items A B C D and D-E-F-G H Part II. Characteristics of Certified Individuals by Tax Credit . This part is divided into three sections 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 target groups. Section J reflects the number of requests IRS Form 8850s certified by the SWA during the current report period by occupation. Section K reflects the number of requests IRS Form 8850s certified by the SWA during the current report period by starting hourly wage. Section I . Section I Column a . Enter the total number of certifications issued by the SW As by target 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 WOTC certifications issued by the SWAs by target group during the current report period. Section I Line 1. Enter the total number of WOTC certifications issued by the SWA during the current report period for the IV-A TANF group. Section I Line 2Ba. Enter the total number of WOTC certifications issued by the SWA during the current report period for Veterans receiving SNAP benefits. Section I Line 2Bb. Enter the total number of WOTC 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 W OTC 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 WOTC 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 WOTC 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 W OTC certifications issued by the SWA during the current report period for Ex-felons Page 3 of 5 ETA Form 9058 ETA Form 9858 Rev. February 2012 SAMPLE Section I. Line 4. P.L. 110-28 changed the name of the High-Risk Youth to Designated Community Residents DCRs . Enter the total number of WOTC certifications issued by the SWA during the current report period for DCRs. Section I Line 5a. Enter the total number of WOTC certifications issued by the SWA during the current report period for Vocational Rehabilitation Referrals. Section I Line 5b. Enter the total number of WOTC certifications issued by the SWA during the current report period for ticket holders. e.g. SSDI or Voc. Rehab . Section I Line 7. Enter the total number of WOTC certifications issued by the SWA during the current report period for Summer Youth . Section I Line 6. Enter the total number of WOTC certifications issued by the SWA during the current report period for SNAP formerly Food Stamps recipients. Section I Line 7. Enter the total number of WOTC certifications issued by the SWA during the current report period for SSI recipients. Section I Line 10. Enter the total number of WOTC certifications issued by the SWA during the current report period for Unemployed Veterans according to P.L. 111 -5. Section I Line 11. Enter the total number of WOTC certifications issued by the SWA during the current report period for Disconnected Youth according to P.L. 111 -5. Section I Line 8. Enter the total number of WOTC certifications issued by the SWA during the current report period for Long-term TANF Recipients. Section I. Line 9. Enter the sums of columns a and b . Note . The total For Qtr. of Part II Section I Line 9 columns a b should equal the total entered in Part I. Item E. Requests Certified. Section I Line 10. Enter the cumulative federal program Year-to-Date YTD totals of columns a and b . Note. The first quarterly report of the federal program year October 1-December 31 the totals of Section I Line 9 and Line 10 should be the same. Section J . Section J Column a . Enter the total number of WOTC Certifications issued by the SW A during the current report period by occupation. Note The total for Section J Column a Line 26 is the sum of the column and must equal the total for Section I Column a b Line 9. The occupational data reported in Boxes 1-22 are derived from the job titles reported on ETA Forms 9061 or 9062. To prepare this report SW As must use the O NET job families of occupations and their two-digit corresponding codes as illustrated in the following table. O NET SOC JOB FAMILIES Name Code Name Code Management Occupations 11 Food Preparation Serving Related 35 Business Financial Operations 13 Bldg. Grounds Cleaning Maintenance 37 Computer Mathematical Occupations 15 Personal Care Service 39 Architecture Engineering 17 Sales Related Occupations 41 Life Physical Social Sciences 19 Office Administrative Support 43 Community Social Services 21 Farming Fishing Forestry 45 Legal Occupations 23 Construction Extraction 47 Education Training Library 25 Installation Maintenance Repair 49 Arts Design Entertainment Sports and Media Occupations 27 Production Occupations 51 Healthcare Practitioner Technical 29 Transportation Material Moving 53 Healthcare Support Occupations 31 Military Specific Occupations 55 Protective Service Occupations 33 Page 4 of 5 ETA Form 9858 Rev. February 2012 SAMPLE Section K Section K Column a . Enter the total number of WOTC certifications issued by the SW A during the current report period by starting hourly wage 1. Note . The total for Section K Column a Line 6 is the sum of the column for that quarter and must equal the total for Section I column b Line 9. Convert as follows Unit of Time Day Amount divided by 8 Calculated Hourly Wage Week Amount divided by 40 Month Amount divided by 172 23. Name and Title of Responsible Official. Enter the name and title of the authorized signatory official. 24. Signature. Enter the signature of the authorized signatory official. 25. Date. Enter the date of the authorized signatory official s signature. 26. Total for qtr . 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 26 is the sum of the column for this quarter and must equal the total for Section I column b Line 9. 1 According to the Federal Labor Standards Act FLSA the federal minimum salary is 7.25 per hour effective July 24 2009. Source Office of Employment Standards Administration Division of W age and Hour at the U.S. Department of Labor. Page 5 of 5 ETA Form 9058 Rev. February 2012 SAMPLE