TEGL_4_12_Att3.pdf

ETA Advisory File Text

Page 1 of 3 ETA Form 9062 Rev. June 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 or www.doleta.gov wotc 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. 1. INITIATING AGENCY CODE For Agency Use Only CODE 2. CONTROL NO . For Agency Use Only One Participating Agency SWA 3. FOR EX-FELON TARGET GROUP ONLY a. Conviction Date c. Correction s Ex-felon s ID No. b. Release Date 4. DATE COMPLETED MM DD YY 5. STATE WORKFORCE AGENCY s NAME ADDRESS 6. SIGNATURE Authorized Official 7. TELEPHONE No. PART I. APPLICANT S INFORMATION AND CONDITIONAL CERTIFICATION CC 8. NAME OF APPLICANT Last First Middle 9. SOCIAL SECURITY No. 10. ENTER TARGET GROUP CODE OTHER THAN Veteran 11. ADDRESS Street City State Zip Code Telephone No. 12. VETERAN TARGET GROUP CODES 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 13. APPLICANT SIGNATURE NOTE TO EMPL OYER 14. 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 ev ent you hire this individual 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 Janaury1 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 15. NAME OF FIRM AND ADDRESS 16. POSITON JOB TITLE 17. EMPLOYMENT-START DATE 18. 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 . 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. 19. EMPLOYER S NAME 20. EMPLOYER S SIGNATURE 21. DATE MM DD YY U.S. Department Labor Employment and Training Administration OMB No. 1205 -0371 Expiration Date June 30 2015 Page 1 of 3 ETA Form 9062 Rev. June 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 pre-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 1-8 and 15 are for participating agency P A 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 SW A s code if available. Indicate with a check mark if initiating agency is a PA or SW A. 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 SW A. Box 3 For Ex-Felon Target Group Only . For items a - c enter the corresponding information. This information will help the SWA or PA in verifying target group eligibility. Note Box 4 does not apply to veterans hired under the VOW to Hire Heroes Act of 2011. Box 4 Date Completed . Enter the month day year in which the eligibility determination was completed. Box 5 SWA s Name and Address . If known enter or stamp the name and address including zip code of the SW A responsible for Certification requests for the employer indicated in Box 16. Leave blank if SW A s name and address is unknown. Box 6 Signature . Enter signature of the authorized conditionally-certifying official. Box 7 Telephone No . Enter corresponding SWA or PA area code telephone number and extension if available. P AR T I . APPLICANT S INFORMATION AND CONDITIONAL CERTIFICATION CC Box 8 Name of Individual . Enter the individual s applicant s full name i.e. last name first name and middle initial . Box 19 Social Security Number . Enter the individual s applicant s Social Security Number. Box 10 Target Group Code . Enter the code or name of the pre-certified non-veteran group. This box does not apply until Congress reauthorizes the non-veteran groups beyond December 31 2011. Box 11 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 12 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. Enter a check mark in front of the veteran group certified. Box 13 Signature . Get applicant s signature. If a minor parent or guardian must sign here. Box 14 CC Validity Period . This box is to be completed by the SW A or PA . Enter the month day year when the CC expires. This box does not apply to veterans pre-certified under the VOW to Hire Heroes Act of 2011. Page 2 of 3 Page 1 of 3 ETA Form 9062 Rev. June 2012 Part II. EMPLOYER DECLARATION Box 15 Name of Firm . Enter full name of the employing firm the firm where the employee will actually work . Box 16 Position Job Title . Enter the position or job title the employee will hold. Box 17 Employment-Start Date . Enter the date the employee began or will begin work for the employing firm. Box 18 Starting Wage . Enter the wage or salary which the employee will be paid. If not known enter an estimated 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 .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