TEGL_4_12_Att5.pdf

ETA Advisory File Text

Work Opportunity Tax Credit Program U. S. Department of Labor Employment Training Administration For SWAs Internal Use Only OMB No. 1205-0371 Expiration Date June 30 2015 1. NAME OF INDIVIDUAL Agency Declaration of Verification Results Worksheet 2. SOCIAL SECURITY NO. 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 CC Issued By Participating Agency or SW A 5. DATE CERTIFIED 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 confirm ed that the 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 PUNISHABLE 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. June 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. June 2012