49740 WOTC Info Collection TEGL_signed (Complete PDF).pdf

ETA Advisory File Text

EMPLOYMENT AND TRAINING ADMINISTRATION ADVISORY SYSTEM U.S. DEPARTMENT OF LABOR Washington D.C. 20210 CLASSIFICATION WOTC CORRESPONDENCE SYMBOL OWI DATE June 23 2023 RESCISSIONS None EXPIRATION DATE Continuing ADVISORY TRAINING AND EMPLOYMENT GUIDANCE LETTER NO. 22-22 TO STATE WORKFORCE ADMINISTRATORS STA TE WORKFORCE AGENCIES STATE WORKFORCE LIAISONS STATE AND LOCAL WORKFORCE BOARDS AND CHAIRS AMERICAN JOB CENTERS WORK OPPORTUNITY TAX CREDIT STATE COORDINATORS FROM BRENT PARTON Acting Assistant Secretary SUBJECT Work Opportunity Tax Credit WOTC Information Collection Revised Forms 1. Purpose. This Training and Employment Guidance Letter TEGL informs State Workforce Agencies SWA partnering agencies employers and other stakeholders of the Office of Management and Budget OMB approval of the extension with revisions of the Work Opportunity Tax Credit WOTC information collection under OMB Control number 1205- 0371. Additionally this TEGL provides clarification on the use of ETA Form 9198 Employer Representative Declaration Form for employers to authorize a third-party representative to act on their behalf to manage WOTC certification requests. 2. Summary and Background. a.Summ ary The WOTC information collection consists of administrative processing and reporting forms which are used by program participants. In accordance with Paperwork Reduction Act PRA requirements the Employment and Training Administration ETA published a Request for Comment Notice in the Federal Register for the proposed extension with revisions of the WOTC information collection before submitting the package to OMB for approval. ETA received a total of 83 comments during the 60-day public comment period which were taken into consideration for the revisions made to ETA Forms 9058 9061 9062 9063 9065 9175 and 9198. The OMB approval of this information collection is effective through May 31 2026. All repor ting and processing forms are available on ETA s website at https www.dol.gov agencies eta wotc. b. Background The WOTC is a Federal tax credit available to employers for hiring from certain categories of workers targeted groups who have consistently faced significant bar riers to employment. The WOTC is set forth under section 51 of the Internal Revenue Code of 1986 as amended 26 U.S.C. 51 and is effective until 2 December 31 2025 under the Consolidated Appropriations Act 2021 Pub. L. 116 - 260 Division EE Title I Subtitle B Section 113. The U.S. Departments of Labor and Treasury jointly administer t he WOTC. Treasury through the Internal Revenue Service IRS administers all tax -related provisions and requirements of the tax credit. Labor through ETA oversees the administration of the WOTC certification process including the allotment of grant funding to SWAs develop ing procedural guidance and provi ding technical assistance and training to WOTC stakeholders . 3. Action Requested . SWAs participating agencies and employers and their representatives are encouraged to start using the OMB -app roved versions of the revised ETA forms as soon as possible effective May 31 2023. The forms are available on the ETA WOTC website at https www.dol.gov agencies eta wotc . ETA requests that SWAs make available the OMB - approved forms on their respective WOTC websites portals and distribute this information with related program staff employers and th eir representatives participating agencies and other interested partners. SWAs must make the revised ETA forms used to submit WOTC certification requests available to employers and other participants by October 1 2023 . Additional information on this t ransition period is detailed below in section 4e of this TEGL. 4. Details . a. SWAs partner agencies employers and their representatives and job seekers should continue to use the following WOTC processing administrative and reporting forms which have not changed in description of purpose WOTC Processing Forms . Employers and jobseekers complete the WOTC processing forms and submit them to the appropriate SWA for processing . SWAs complete a three -step application review process which includes forms intake verification and notifications. ETA Form 9061 Individual Characteristics Form ICF . Note The Spanish - ETA Form 9061 is available for translation purposes only. ETA Form 9062 Conditional Certification CC . ETA Form 9175 Self -Attestation Form SAF for Qualified Long -Term Unemploym ent Recipient LTUR . WOTC Reporting Forms . Reporting forms are used quarterly by ETA grantees SWAs . SWAs must report fiscal expenditures using ETA Form 9130 and program activities using ETA Form 9058 . Note ETA Form 9130 used for financial reporting is covered under a separate OMB Control No. ETA Form 9058 WOTC Report 1 Certification Workload and Characteristics of Certified Individuals . 3 WOTC Administrative Forms . WOTC administrative forms are used by SWAs and employers or their authorized representatives if applicable for recordkeeping purposes . ETA Form 9063 Employer Certification . This form is not available online . ETA Form 9065 Agency Declaration of Verification Results ADVR Worksheet . ETA Form 9198 Employer Representative Declaration Form . Note ETA Form 9198 is a new form approved under this information collection request and was not under the prior OMB approval through March 31 2023. b. OMB Approval of Several New WOTC Forms . ETA Forms 9061 9062 9063 9065 9175 and 9058 which had previously been approved by OMB for use through March 31 20 23 are now approved for use under the PRA of 1995 under OMB Control No. 1205 -0371 for an additional three -year period through May 31 2026 . ETA Form 9198 is also approved by OMB fo r use through May 31 202 6. The U.S. Department of Labor notes that a Federal agency may not conduct or sponsor a collection of information nor is the public required to respond to a collection of information unless it is approved by OMB under the PRA a nd displays a currently valid OMB control number 44 U.S.C. 3507 . Also notwithstanding any other provision of law no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number 44 U.S.C. 3512 . c. Revi sed Forms and Instructions . Program participants employers job seekers SWAs and partner agencies should use the newly approved ETA Forms to submit and process WOTC certification requests effective May 31 2023 . If employers submit expired ETA forms March 31 2023 expiration date after June 1 2023 SWAs should accept and process those forms in adherence to TEGL 16 -20 Work Opportunity Tax Credit WOTC Procedural Guidance or the applicable ETA Advisory in effe ct at the time of certification request review. The WOTC processing reporting and administrative forms have been updated to reflect general grammatical syntax and or formatting revisions. The corresponding form instructions were also updated to remove outdated policy guidance statutes or expired provisions of the tax credit. Many of the form adjustmen ts were minimal and non -substantive in nature reformatted in a user -friendly style. Examples given ETA received numerous requests to update the date -of -birth format mm dd yyyy and include the applicant s full social security number across all requir ed WOTC forms . ETA also considered and incorporated substantive changes to the ICR in response to public comments received during the 60 -day public comment period . Specific form revisions are as follows ETA Form 9061 Revised form 9061 includes a formatting design update which more clearly separates the sections for different targeted groups and simplifies the eligibility statements 4 questions for the job applicant employer to complete. A field was added to provide space for multiple states in res ponse to questions pertaining to where public welfare benefits were received. This addition will help states easily identify when certification requests need to be verified by other SWAs and or participating agencies. ETA Form 9062 Revised Form 9062 inc ludes minor formatting updates to make a better distinction between the respondent employer versus job applicant sections. ETA Form 9175 Revised Form 9175 includes minor formatting updates to clearly identify th at th e job applicant not the employer is self -attest ing to their period s of unemployment. ETA Form 9063 Revised Form 9063 includes minor stylistic updates including slight syntax edits to clearly identify the information being collected for the employer and employee . ETA Form 9058 Revis ed Form 9058 includes updates to the reporting fields completed by the SWA. For program activity the revised form will capture the number of out -of-state certification requests received by the SWA reasons for denials issued by the SWA and updated hou rly wage brackets to track overall impact across higher income levels. Revised instructions reflect the new added fields for SWA input and output workload activities. SWAs will use the revised form for fiscal year 2024 reporting. ETA Form 9065 Revised Form 9065 includes stylistic formatting updates which more clearly identify the type of information being requested of the SWA . The form instructions include details on how SWAs should complete any necessary follow -up activities such as notices o f invalidations for invalid certifications issues as a result of quarterly audits per TEGL 16 -20 guidance. ETA Form 9198 ETA Form 9198 replaces the use of IRS Form 2848 Power of Attorney and Declaration of Representative for employers to authorize an individual to represent them for WOTC purposes. ETA will provide additional technical assistance to SWAs on form instructions . IRS Form 8850 IRS Form 8850 Pre -Screening Notice and Certification Request for the WOTC and its Instructions are available online at https www.irs.gov forms -pubs about -form - 8850 . IRS Form 8850 has been authorized by OMB for use through June 30 2025 . Note IRS Form 8850 is under OMB Control No. 1545 -1500 and not a part of ETA s WOTC information collection. Employers and their representatives are encouraged 5 to visit the IRS website https ww w.irs.gov forms -pubs about -form -8850 for additional information . d. General Instructions . Although electronic and facsimile submission of WOTC Forms is permitted not all states are equipped to accept an electronic or faxed copy of documents . Employers should confirm acceptable submission methods with the SWA prior to form submission. Forms with an electronic e - signature image or digitized image o f a handwritten signature may only be used if the employer s system satisfies the requirements in IRS Ann. 2002 -44 2002 -1 C.B. 809. Guidance on acceptable electronic e - signature methods is provided in IRS Notice 2012 -13 2012 - 9 I.R.B. 421 available at https www.irs.gov pub irs -drop n -12 -13.pdf . e. Transition Period for State Workforce Agencies and Employers . To ensure the smooth and uninterrupted submission of employers certification requests for their new hires ETA is granting a transition period that allows employers to continue to submit applications using the old ETA Forms 9061 9062 9175 expiration da te March 31 2023 for a temporary period. SWAs participating agencies employers and their representatives are encouraged to start using the recently OMB -approved versions of the revised ETA forms as soon as possible including ETA Form 9198 . Use of the revised ETA forms OMB expiration date May 31 2026 will be required to submit certification request s to SWAs for new hire s effective October 1 2023 . After that date employers should not submit olde r expired versions of ETA Forms 906 1 9062 and or 9175 . During the transition period SWAs must permit employers to continue to use either the old March 2023 or the revised May 2026 versions of ETA Forms 9061 9062 and 9175 . Additionally SWAs should work to update their internal WOTC management systems including employer authorized representative management systems to reflect changes to the revised ETA Forms and make these forms available to employers participating agenc ies and other stakeholders by the end of the 90 -day transition period. f. Guidance for Use of and Transition Period for ETA Form 9198 . Under TEGL 16 -20 Work Opportunity Tax Credit WOTC Procedural Guidance available at https www.dol.gov agencies eta advisories training -and -employment -guidance - letter -no -16 -20 employer s may author ize an individual to represent them for WOTC purposes by submitting an IRS Form 2848 Power of Attorney and Declaration of Representative to the SWA in which the employer s business is located . ETA recognize d the concerns raised by SWAs and employers and their representative s regarding IRS Form 2848 instructions and its applicability to WOTC and through this information collection request ETA developed Form 9198 Employer Representative Declaration Form for employers to authorize a represe ntative s to facilitate the WOTC certification request process on their behalf. ETA Form 9198 will replace the use of IRS Form 2848 for employers to authorize representation under WOTC effective June 1 2024. The current expiration date of IRS Form 2848 is May 31 2024 OMB Control No. 1545 -0150 . 6 ETA recognizes that employers may have current authorizations IRS Form 2848 on file with the SWA that have an effective years or period end date that extends beyond May 31 2024. However in an effort t o transition from the use of IRS Form 2848 to ETA Form 9198 for employer representative declarations ETA will update WOTC procedural guidance TEGL 16 -20 to advise employers that effective June 1 2024 use of IRS Form 2848 to authorize employer represen tatives under WOTC will be discontinued. As a result all IRS Form 2848 authorizations will automatically terminate on June 1 2024 regardless of the Years or Periods end date indicated in section 3 of the Form. SWAs may continue to recognize the effe ctive period end date listed if the date falls on or before May 31 2024. SWAs should update their employer representative management systems and or processes to terminate all IRS Form 2848 employer authorizations effective June 1 2024. Effective this date employers must use ETA Form 9198 to re authorize employer representatives. Employers may use and SWAs may accept ETA Form 9198 effective immediately. SWAs should begin to update their internal controls and processes to manage employer repre sentative authorizations using ETA Form 9198 and work with employers and other stakeholders to assist in transition from use of IRS Form 2848 to ETA Form 9198 effective the publication date of this TEGL . ETA Form 9198 does not constitute a formal power of attorney arrangement between the employer and its representative but it will allow the representative to conduct authorized WOTC activities as listed in the Authorized Representatives section of TEGL 16 -20 . In general formal power of attorney designations should not be required for employer representatives to conduct WOTC business with the SWAs and ETA discourages SWAs from imposing additional requirements for documenting employer representative declarations beyond th e requirements listed in ETA s procedural guidance. As such ETA will issue updated procedural guidance for the WOTC certification process including how SWAs will manag e employer representative declarations using ETA Form 9198 in TEGL 16 -20 Change 1. ETA Form 9198 provides information to employers on how to authorize an individual s to represent them during the WOTC certification process including how an employer may authorize multiple representatives according to ETA Form 9198 Instructions and WOTC recordkeeping requirements listed in TEGL 16 -20 . There are specific instructions for SWAs to note for the use of ETA Form 9198 as follows Line 1. Employer Information . The employer identification number EIN listed on Form 9198 must be a tax -identification number that is registered in the state where the employer s business is located and WOTC certification requests are submitted . Employers should verify with the SWA that the appropriate EIN is provided consi stently across IRS Form 8850 and ETA Forms 9198 and or 9061 as applicable. Line 2. Representative s . SWAs are required to send notices and communications to a minimum of two 2 Employer Representatives with the same organization as designated in Line 2. SWAs may choose to allow employers to list additional 7 representatives as an appendix to Form 9198. See Form Instructions page 4 for additional details. Line 3. Acts Authorized . Representative s shall have the authority to perform the act ivities described on pages 1 -2 of Form 9198 with respect to the WOTC certification process . These activities include the authority to complete and sign IRS Form 8850 and related ETA Forms on behalf of the employer and substitute or add representative s within the same company under a valid authorization form. Line 3. Acts Authorized . The A uthorization period listed cannot exceed five 5 years and will automatically terminate on the applicable end date unless revoked or withdrawn earlier by either party. The designation of Year s or Period s cannot be retroactive from the signature date of the employer declaration. Employers may not specify years or periods that have ended as of the effective date of the authorization. Note the date the Employer signs the declaration form Line 5 is the effective date of the authorization . Line 4. Retention Revocation of Prior Authorization . The filing of an Employer Representative Declaration Form will not automatically revoke prior authorizations on file with the SWA for the same matters and years or periods cove red by th e form. Employers must check the applicable box on page 2 and attach a copy of any prior authorization s to be revoked if the employer want s to revoke prior authorizations . 5. Inquiries . Please direct inquiries to the appropriate Regional WOTC Coordinator listed on the WOTC website at https www.dol.gov agencies eta wotc contact regional -offices . 6. References . Section 51 of the Internal Revenue Code of 1986 as amended https usc ode.house.gov view.xhtml path prelim title26 subtitleA chapter1 subchapt erA part4 subpartF edition prelim Pub. L. 11 6-260 Consolidated Appropriations Act of 202 1 https www.congress.gov 116 plaws publ260 PLAW -116publ260.pdf Pub. L. 104 -13 Paperwork Reduction Act of 1995 https www.congress.gov 104 plaws publ13 PLAW -104publ13.pdf Federal Register Notice 87 FR 69048 Agency Information Collection Activities Comment Request Work Opportunity Tax Credit November 17 2022 https www.federalregister.gov documents 2022 11 17 2022 -25037 agency - information -collection -activities -comment -request -work -opportunity -tax -credit and Training and Employment Guidance Letter No. 16-20 Work Opportunity Tax Credit WOTC Procedural Guidance https www.dol.gov agencies eta advisories training - and -employment -guidance -letter -no -16 -20 . 7. Attachment s . Attachment I ETA Form 9061 Individual Characteristics Form ICF Attachment II ETA Form 9062 Conditional Certification CC Attachment III ETA Form 9175 Self -Attestation Form SAF for Qualified Long -Term Unemployment Recipient LTUR 8 Attachment IV ETA Form 9198 Employer Representative Declaration Form Attachment V ETA Form 9065 Agency Declaration of Verification Results ADVR Wo rksheet Attachment VI ETA Form 9058 WOTC Report 1 Certification Workload and Characteristics of Certified Individuals 1 ETA Form 9061 Rev. May 2023 Employment and Training Administration OMB Control No. 1205-0371 Expiration Date May 31 2026 1. Control No. For Agency use only SWA AGENCY INFORMATION See instructions on pg 4 2. Date Received For Agency Use only EMPLOYER INFORMATION 3. Employer Name 4. Employer Mailing Address Telephone No. and Email Address 5. Employer Identification Number EIN JOB APPLICANT INFORMATION 6. Applicant Name Last First MI 7. Social Security Number U - - 8. Have you worked for this employer before YES NO JOB APPLICANT CHARACTERISTICS FOR WOTC TARGET ED GROUP S CERTIFICATION 9.Employment Start Date10. Starting Wage11.Job Position Title or SOC Standard Occupation Classification UDirections U Read the following statements carefully and check any of following statements that apply to the job applicant. Provide additional information where requested and as needed for targeted group eligibility determination. 12. Qualified IV -A Recipient Check here if the job applicant is a Qualified IV-A Recipient If the job applicant is a member of a family receiving Temporary Assistance for Needy Families TANF enter the name of the primary benefits recipient and the c ity and state s where benefits were received 13. Qualified Veteran Check here if the job applicant is a veteran of the U.S. Armed Forces If the job appli cant veteran is a member of a family receiving Supplemental Nutrition Assistance Program SNAP benefits enter the name of the primary benefits recipient and the city and state s where benefits were received . Note Additional information may be requested to determine the job applicant s qualified veteran eligibility such as proof of being entitled to compensation for a service-connected disability or having aggregate periods of unemployment. 14. Qualified Ex -Felon Check here if the job applicant is an Ex-Felon Enter date of felony conviction mm dd yyyy and release date Federal conviction State conviction List applicable state . U.S. Department of Labor Check here if the job applicant is in a Work Release Program 15. Designated Community Resident DCR Check if the job applicant is at least age 18 but not age 40 on the hiring date and resides i n aRural Renewal Coun ty RRC or an Empowerment Zone EZ . Enter job applicant s birthday mm dd yyyy . 16. Vocational Rehabilitation Referral Check here if the job applicant is a Vocational Rehab ilitation VR Referral 17.Qualified Summer Youth Employee Check here if the job applicant is a Qualified Summer Youth Employee Enter the job appli cant s birthday mm dd yyyy 18.Qualified Supplemental Nutrition Assistance Program SNAP Recipient Check here if the job applicant is a Qualified SNAP Food Stamps Recipient Enter job applicant s birthday mm dd yyyy Enter the name of t he primary benefits recipient U U and the city and state s where benefits were received . 19.Qualified Supplemental Security Income SSI Recipient Check here if the job applicant received or is receiving Supplemental Security Income SSI 20. Long-Term Family Assistance Recipient Check here if the job applicant is a Long-term Fa mily Assistance long-term TANF recipient Enter name of the primary benefits recipient U U and the city and state s where benefits were received . 21. Qualified Long-Term Unemployment Recipient Check here if the job applicant is a qualified long-term unemployment recipient LTUR Enter city and state s where UI claim records UI wage records were filed . 22.Sources used to document eligibility. List all supporting documentation submitted to SWA. Indicate next to each document listed whether it is attached A or forthcoming F . SWA Staff List all supporting documentation used in determining targeted group eligibility for the applicant. Enter your initials and date when the 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 in Box 23. b for who signs this signature block 23. b Indicate who signed this form Employer Employer s Preparer SWA P articipating Agency Job Applicant Parent Guardian if job applicantis a minor 24.Signature Date 3 ETA Form 9061 Rev. May 2023 INSTRUCTIONS FOR COMPLETING THE INDIVIDUAL CHARACTERISTICS FORM ICF ETA 9061. This form must be used together with IRS Form 8850 to help state workforce agencies SWAs determine eligibility for the Work Opportunity Tax Credit WOTC . The form may be completed on behalf of the job applicant by 1 the employer or employer s representative 2 the applicant directly if a minor the parent or guardian must sign the form or 3 a participating agency 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. Eligibility requirements for each 31TUtargeted group is available on the IRS.gov website U31T. Additionally information on how to submit certi fication requests including WOTC Processing Forms. B ox 1 and 2. State Workforce Agency SWA or Participating Agency. For agency use only. Box 3 - 5. Employer Information. Enter the name address including ZIP code telephone number and employer identification number EIN of the employer requesting WOTC certification. Note The EIN number must be a tax-identification number that is registered with the state where the business is located so the SWA can establish an employer-employee relationship where wages are paid and federal taxes deducted . Do not enter information pertaining to the employer s representative if any. Box 6 - 11. Applicant Information. Enter the applicant s full name and social security number as they appear on the applicant s social security card. For job title position enter the job applicant s job title or the corresponding standard occupation classification SOC . In Box 8 indicate whether the job applicant previously worked for the employer. This information will help the SWA to determine if the job applicant is a first-time qualifying member of a WOTC targeted group s . For additional information about non-qualifying rehires see 26 U.S.C. 51 i 2 . B ox 12 - 21. Applicant Characteristics. Read statements carefully check any boxes that apply and provide additional information where requested. Eligibility requirements for each targeted group is available on the IRS.gov website. Box 22. Sources to Document Eligibility. Employers and SWAs use this box to list the sources used to verify target group eligibility. Indicate in parentheses next to each doc ument listed whether it is attached A or forthc oming F . SWAs should follow this notation with their initials and the date the eligibility determination was completed Some examples of acc eptable documentation are pr ovided below. Examples of Documentary Evidence and Collateral Contacts. Employers You may check with your SWA to find out what other sources you can use to verify targeted group eligibility. You are encouraged to provide copies of documentation for each checked box . QU ESTIONS 12 18 20 TANF SNAP Food Stamp Benefit History or Case Number Identifier Signed statement from Authorized Individual with a specific description of the months benefits that were received. QU ESTION 13 DD-214 or Discharge Papers Reserve Unit Contacts Letter of Separation or other agency documents issued only by the Dep artment of Veterans Affairs DVA on DVA Letterhead certifying the Veteran has a service-connected disability and signed by the individual who verified this information. UI Claims Records or UI Wage Records for unemployed veteran sub-categories QU ESTION 14 Parole Officer s Name or Statement Correction Institution Records Court Records Extracts QU ESTIONS 15 17 Birth Certificate or Copy of Hospital Record Driver s License School I.D. Card1 Work Permit1 Federal State Local Gov t I.D. To determine if a Designated Community Resident lives in a Rural Renew al County visit the US Postal Service website 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 Instructions to IRS 8850 Form. For additional information see the Instructions for the IRS Form 8850 and the Em powerment Zone EZ Locator Tool available on the dol. gov website. QU ESTION 16 Vocational Rehabilitation Agency Contact 4 ETA Form 9061 Rev. May 2023 Veterans Administration for Disabled Veterans Signed letter of separation or related document from authorized Individual on DVA letterhead or agency stamp with specific description of months benefits were received. QUESTION 19 SSI Record or Authorization Evidence of SSI Benefits SSI Contact For SWAs To determine eligibility for SSI and or TTW Ticket Holders send verification requests to the USDOL designated agency contact. QUESTION 21 Unemployment Insurance UI Wage Records UI Claims Records Self-Attestation Form ETA Form 9175 BOX 22 List all sources used and provided to the SWA to document targeted group eligibility. SWA Staff List all documentation used to determine verify eligibility in the targeted group s requested by the employer representative to reach the final determination. Note 1. Where a Federal State Local Gov t. School I.D. Card or Work Permit does not contain age 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 longer a valid piece of documentary evidence. Box 23 a . Signature. The person who completes the form signs the signature block. Box 23 b . Signature Options. a Employer or their Authorized Representative b SWA staff c Participating Agency staff or d Applicant If applicant is minor the parent or guardian must sign . Box 24. Date. Enter the month day and year when the form was completed. Note An employer s authorized representative can be verified through an executed Employer Representative Authorization Form ETA Form 9198 . The representative is able to facilitate WOTC activities which includes but is not limited to Completing signing and submitting WOTC processing forms Requesting status application updates Providing clarifying information including supporting documentation Receiving copies of notices and communications and Submitting employer appeals. 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 Washi ngton 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. Page 1 of 3 ETA Form 9062 Rev. May 2023 U.S. Department of Labor Employment and Training Administration OMB Control No. 1205 -0371 Expiration Date May 31 2026 Work Opportunity T ax Credit Conditional Certification Form CC INSTRUCTIONS FORM EMPLOYERS This form must be accompanied by IRS Form 8850. If you do not have IRS Form 8850 download it from 26TUhttps www.irs.gov U26T. Be sure to complete Part II of this Form and IRS 8850. Sign and date both Forms BEFORE sending them to the State Workforce Agency SWA within 28 days after the new hire s employment start date. See reverse side for additional Form instructions. PARTICIPATING AGENCY STATE WORKFORCE AGENCY SWA INFORM ATION 1. INITIATING AGENCY CODE For Agency Use Only 2. CONTROL NO . For Agency Use Only Check One SWA Participating A gency 3. DATE COMPLETED mm dd yyyy 4. SWA S NAME MAILING ADDRESS 5. TELEPHONE NUMBER 6. AUTHORIZED SIGNATURE Agency SWA Official PART I. APPLICANT S INFORMATION AND CONDITIONAL CERTIFICATION CC 7. NAME OF APPLICANT Last First Middle 8. APPLICANT S ADDRESS Include Street City State Zip Code AND TELEPHONE NUMBER 9. APPLIC A NT s SOC IA L S ECURITY NUMBER 10. ENTER TARGETED GROUP CODE NO. TARGETED GROUP NAME for the applicant seeking certification 11.QUALIFIED VETERAN TARGETED GROUP CODES Please Check 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 12. FOR EX-FELON TARGETED GROUP a. State or Federal Conviction .. b. Conviction Date c. Release Date d. Ex-felon s Corrections ID No. 13. FOR SUMMER YOUTH EMPLOYEE TARGETED GROUP The job appli cant may be eligible for WOTC certification. If the individual is not employed before the date in the box above enter MM DD YYYY this eligibility determination is subject to review. 14. APPLICANT S SIGNATURE DATE Note to Employers In the event that you hire this individual you should request the necessary Certification from the SWA for you to claim the Work Opportunity Credit. Complete sign and submit this Form together with IRS Form 8850 to the SWA in which your business is located. IRS Form 8850 must be submitted to the SWA within 28 calendar days of the new hire s start date to meet timely filing requirement. If all statutory targeted group eligibility and timely filing requirements have been met for your certification request the SWA will issue you an Employer Certification. PART II. EMPLOYER DECLARATION I hereby declare that the above-named applicant is or will be employed by the date provided below in box 16. 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. 15. NAME OF FIRM COMPANY AND FIRM S MAILING ADDRESS 16. APPLICANT S EMPLOYMENT START DATE MM DD YY . 17. POSITON JOB TITLE 18. STARTING WAGE per hr ATTN SWA Please send an Employer Certification for this employee. This pre-certification is for the purpose of requesting the Work Opportunity Credit 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. 19. EMPLOYER S NAME 20. EMPLOYER S SIGNATURE 21. DATE MM DD YY Page 2 of 3 ETA Form 9062 Rev. May 2023 CONDITIONAL CERTIFICATION CC ETA FORM 9062. When a state workforce agency SWA or participating agency PA determines that a job-ready applicant is TENTATIVELY ELIGIBLE as a member of a targeted group under WOTC the agency shall use this required CC Form without modification to show that eligibility pre-determination was made for the applicant. Note The CC serves as an official record of the pre-certification alerts prospective employers to the availability of the tax credit if the applicant is hired and provides a means for employers to request a WOTC Employer Certification for the applicant. INSTRUCTIONS FOR COMPLETING ETA FORM 9062 CONDITIONAL CERTIFICATION BOXES 1 - 6 ARE FOR PARTICIPATING AGENCY STATE WORKFORCE AGENCY SWA USE ONLY. Box 1 Initiating Agency Code. If the CC was issued by a Participating Agency PA 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 s code. Indicate with a check mark if initiating agency is a PA or SWA. Box 2 Control N umber. 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 code 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 Date Comp leted. Enter the month day year in which the eligibility determination was completed Box 4 SWA s Name an d Address. If known enter or stamp the name and address including zip code of the State Workforce Agency SWA responsible for processing certification requests for the employer indicated in Box 15. Leave blank if SWA s name and address is unknown. Box 5 Tele phone No. Enter corresponding SWA or PA area code telephone number and extension if applicable. Box 6 Signatur e. Enter signature of the authorized conditionally-certifying official. PART I. APPLICANT S INFORMATION AND CONDITIONAL CERTIFICATION CC Box 7 Name of Applicant. Enter the individual s job applicant s full name i.e. last name first name and middle initial . Box 8 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 9 Social Security Number. Enter the individual s applicant s Social Security Number as it appears on their Social Security Card. Box 10 Targe ted Group Code. Enter the code or name of the pre-certified targeted group. For targeted group names and eligibility definitions visit 26Thttps www.irs.gov businesses small-businesses-self-employed work-opportunity-tax-credit targeted 26T. Box 11 Veter an Targeted Group Codes. The original targeted group designation for a Qualified Veteran is B. To facilitate the identification of the different subcategories of qualified veterans created by the VOW to Hire Heroes Act of 2011 P.L. 112-56 and to ensure a simple uniform and consistent certification system which can be used by the SWAs nationwide ETA uses the same alpha-numeric designations for the qualified veteran categories used in ETA Form 9058 WOTC Report 1. Each 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 qualified veteran subgroup for which the applicant is pre-certified. Box 12 For Ex-Fel on Targeted Group Only. For items a - d enter the corresponding information. This information will help the SWA or PA in verifying targeted group eligibility. Box 13 CC Valid ity Period For Summer Youth Employee Targeted Group Only . This box is to be completed by the SWA or PA . Enter the month day year when the Conditional Certification expires. This box does not apply to qualified veterans nor any other targeted group under Section 51 of the Internal Revenue Code except for Summer Youth Employee applicants. Box 14 Signatur e. Get the job applicant s signature. If the applicant is a minor the parent or guardian must sign. Enter date. PART II. EMPLOYER DECLARATION EMPLOYER INFORMATION Box 15 Name of Company Firm. Enter full name of the employing firm the firm where the employee receives wages from . Box 16 Emplo yment-Start Date. Enter the date the employee began or will begin work for the employing firm. Box 17 Posit ion Job Title. Enter the position or job title the employee will hold was offered employment under. Box 18 Start ing Wage. Enter the wage or salary which the employee will be paid was hired under. If not known enter an estimated hourly wage. Page 3 of 3 ETA Form 9062 Rev. May 2023 Box 19 Emp loyer s Name. Enter your name as the hiring employer. Box 20 Emp loyer 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 20 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 by 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 . . U.S. D epartment of Labor Em ployment and Training Administration OMB Control No. 1205-0 371 Expiration Date May 31 2026 ETA Form 9175 Rev. May 2023 Work Opportuni ty Tax Credit LONG-TERM UNEMPLOYMENT RECIPIENT LTUR SELF-ATTESTATION FORM SAF Instructions The Self-Attestation Form SAF is to be completed signed and dated by the applicant new hire only. Employers or their authorized representatives should submit the completed SAF along with IRS Form 8850 Pre-Screening Notice and Certification Request for the Work Opportunity Tax Credit or if filed separately with ETA Form 9061 ETA Form 9062 to the State Workforce Agency SWA for each certification request submitted for the Long-Term Unemployment Recipient LTUR targeted group. Applicant Self-Attestation Under penalties of perjury I declare that the information below is true and correct to the best of my knowledge. Applicant s Full Name Print First Middle Initial Last Applicant s Signature Date Applicant s Social Security Number Date of Birth mm dd yyyy Employer s Nam e Employer s Firm Company Name UApplicant Instructions U Please check the statement below if it applies to you and fill in t he requested information below. I declare that I was am in a period of unemployment that was is at least 27 consecutive weeks and for all or part of that unemployment period I received unemployment compensation under State or Federal law. State s unemployment compensation was received I have been in a period of unemployment since Enter unemployment start date mm dd yyyy Privacy Act Notice Section 51 of the Internal Revenue Code of 1986 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 process. The information you have provided by 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 to determine your employer s eligibility for the federal work opportunity tax credit. Public Burden Statement Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Respondents obligation to complete this Form is required to obtain or retain benefits P.L. 111-5 . Public reporting burden is estimated to average 10 minutes 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 to the U.S. Department of Labor Division of National Programs Tools Technical Assistance Room C-4510 Washington D.C. 20210 Paperwork Reduction Act OMB Control No. 1205-0371 . Please do not submit completed WOTC processing forms to this address. ---- ------------------ ---- U.S. Department of Labor Employment and Training Administration OMB Control No. 1205 -0371 Expiration Date May 31 2026 ETA Form 9198 May 2023 For Privacy Act and Paperwork Reduction Act Notice see the instructions. Work Opportunity Tax Credit WOTC ETA Form 9198 Employer Representative Declaration Part I. Authorized Representative s Note Form 9198 will not be honored for any purpose other than declaring Employer Representative s with the State Workforce Agency SWA for employer WOTC certification requests. 1.Employer Information. Employer must sign and date this form on page 2 Part II Line 5. Employer Name and Mailing Address Employer Tax Identification Number EIN Employer s Firm Company Name Telephone Number Fax Number Email Address The employer hereby appoints the following person s as authorized employer representative s 2.Representative s . Representatives must sign and date the form on page 2 Part II Line 6. Note SWAs must send notices and communications to two 2 designated Employer Representatives. Last Name First Name Company Name Company Mailing Address Telephone Number Fax Number Email Address Check if to be sent copies of Employer s WOTC notices and communications. Last Name First Name Company Name Company Mailing Address Telephone Number Fax Number Email Address Check if to be sent copies of Employer s WOTC notices and communications.------------------- to represent the employer for WOTC purposes and perform the following activities 3. Acts Authorized. You are required to acknowledge Line 3 Acts Authorized with employer initials . I employer authorize my representative s to facilitate the WOTC certification request process on my behalf. My representative s shall have the authority to perform acts I can perform with respect to the WOTC certification process described below. Complete and sign IRS Form 8850 Pre-Screening Notice and Certification Request for the Work Opportunity Tax Credit on behalf of the employer For Privacy Act and Paperwork Reduction Act Notice see the instructions. ETA Form 9198 May 2023 U.S. Department of Labor Employment and Training Administration Submission of IRS Form 8850 and ETA Forms 9061 9062 9175 with supporting documentation to the appropriate SWA Submitting missing information or documentation that is necessary for a certification request Communicate directly with the SWA to provide updates or clarifying information regarding an employer s certification request Receiving copies of notices or communications related to an employer s certification request Substitute or add representative s within the same company. Initial here to acknowledge acts authorized for representative s . Employer Initials Year s or Period s if applicable Note The Employer Authorization designation of Year s or Period s cannot be retroactive from the signature date of the employer declaration in Part II. Employers may not specify years or periods that have ended as of the date the Employer signs the authorization Line 5 . The Authorization period listed in Line 3 Acts Authorized cannot exceed five 5 years and will automatically terminate on the applicable end date unless revoked or withdrawn earlier by either party. 4.Retention Revocation of Prior Authorization. The filing of this Employer Representative Declaration Form will not automatically revoke prior authorizations on file with the SWA for the same matters and years or periods covered by this form. If you want to revoke a prior authorization s check the box and attach a copy of any prior authorization s to be revoked. .............................................................................................................................................................. YOU MUST ATTACH A COPY OF ANY EMPLOYER REPRESENTATIVE DECLARATION YOU WANT TO REVOKE. Part II. Declaration of Employer and Representative s and Signatures 5. Employer Declaration and Signature. I certify I have the legal authority to execute this form as or on behalf of the Employer. If signed by an individual other than the Employer specified in Part I. indicate. Employer Signature Dat e Printed Name Relationship to Employer Self Other Signatory Title Company Name 6. Repr esentative Declaration and Signature s . Under penalties of perjury by my signature below I declare I am authorized to represent the Employer identified in Part I for the matter s specified there. Representative Signature Date Printed Name Representative Signature Date Printed Name IF NOT COMPLETED SIGNED AND DATED THIS AUTHORIZATION IS INVALID AND THE SWA WILL RETURN THIS FORM TO THE EMPLOYER. For Privacy Act and Paperwork Reduction Act Notice see the instructions. ETA Form 9198 May 2023 U.S. Department of Labor Employment and Training Administration ETA Form 9198 Employer Representative Declaration General Instructions Purpose of Form Use Form 9198 to authorize an individual to represent you employer for WOTC purposes. Check with your State Workforce Agency SWA for information about using a substitute form other than a Form 9198 to authorize an individual to represent you for WOTC purposes. Your authorization of a representative will allow that individual to facilitate your WOTC certification requests including submitting WOTC processing forms IRS Form 8850 and ETA Forms 9061 9062 9175 and supporting documentation or information on behalf of the employer. For the latest information about developments and 32TUinstructions related to Form 9198 U32T. How To File Submit a copy of the completed form to the SWA where the employer files WOTC certification requests state where the employer s business is located . You can choose how to submit Form 9198 from the options below. Although electronic and facsimile submission of Form 9198 is permitted not all states are equipped to accept an electronic or faxed copy of Form 9198. Employers should confirm acceptable submission methods with the SWA prior to form submission. To get the name address phone fax numbers and email address of the WOTC coordinator for your state visit the Department of Labor s WOTC page website at . Note If you use an electronic signature see Electronic Signatures below you must submit your Form 9198 online. Online. Submit your Form 9198 via online portal. Note You will need to have a registered account with the SWA s online portal to submit your Form 9198 online. Contact your local SWA to request secure portal access or account. Fax. Fax your Form 9198 to the appropriate fax number registered with the SWA. Mail. Mail your Form 9198 directly to the SWA via certified U.S. Postal Mail. e-mail. E-mail your Form 9198 directly to the SWA. Confirm this option is available with the specific SWA . Electronic Signatures Forms 9198 with an electronic e- signature image or digitized image of a handwritten signature may only be used if the employer s system satisfies the requirements in IRS Ann. 2002-44 2002-1 C.B. 809. Guidance on acceptable electronic e- signature methods is provided in IRS Notice 2012-13 2012-9 I.R.B. 421. A typed name that is typed into the signature block A scanned or digitized image of a handwritten signature that is attached to an electronic record A handwritten signature input onto an electronic signature pad or A handwritten signature mark or command input on a display screen with a stylus device.Note I f the employer electronically signs Form 9198 in a remote transaction a third-pa rty submitting Form 9198 to the SWA on behalf of the employer must attest that he or she has authent icated the employer s ide ntity unless the t hird party has personal knowledge allowing the third party to authenticate the employer s identity. F or example t hrough a prior business relationship a personal relationship such as an immediate family member or a similar relationship such as between an employer and an employee . A remote transaction for an electronic signature occurs when the employe r is electronically signing the form and the third-pa rty submitter isn t physically present wi th the employer. Aut hority Granted Except as spec ified below or in other ETA guidance thi s Employer Repr esentative Declaration Form authorizes the l isted representative s to perform acts that you ca n perform with respect to the f acilitation of WO TC certification requests described in the Declaration. Repr esentatives are not author ized to inspect and or receive the employer s confidential tax information or to perform any acts i .e. sign agr eements or other documents not descri bed in the Declaration. Representative Address ChangeIf th e Representative s address has chan ged the SWA will not requi re a new Form 9198 to update the new addr ess. The employer or representative can send a written notification that inc ludes the new contact information and the representative s signature to the same SWA as where the employer filed Form 9198. OMB Control No. 1205-0371 Expiration Date May 31 2026 For Privacy Act and Paperwork Reduction Act Notice see the instructions. ETA Form 9198 May 2023 U.S. Department Labor Employment and Training Administration Revocation by Employer. If you employer want to revoke a previously executed Employer Representative Declaration and do not want to name a new representative you must write REVOKE across the top of the first page of this form with a current signature and date below this annotation. You must then submit a copy by postal mail fax or online of the original Declaration with the revocation annotation to the SWA where the business is located and WOTC certification requests are submitted . If you do not have a copy of the Declaration you want to revoke you must send the SWA a statement of revocation that indicates the authority of the Declaration is revoked lists the matters and years periods and lists the name and address of each recognized representative whose authority is revoked. You must sign and date this statement. If you are completely revoking authority write remove all years periods instead of listing the specific matters and years periods. Withdrawal by Representative. If your representative wants to withdraw from representation they must write WITHDRAW across the top of the first page of the form Declaration with a current signature and date below the annotation. Then they must provide a copy of the original Declaration with the withdrawal annotation to the SWA where the business is located and original Declaration was submitted in the same manner described in Revocation by Employer earlier. If your representative does not have a copy of the Declaration he or she wants to withdraw he or she must send the SWA a statement of withdrawal that indicates the authority of the Declaration is withdrawn lists the matters and years periods and lists the name employer identification number EIN and address if known of the Employer. The representative must sign and date this statement. Specific Instructions Part I. Authorized Representative s Line 1. Employer Information Enter the information requested about you employer . Do not enter information about any other person except as stated in the specific instructions below. Address information provided on Form 9198 will not change your last known address registered with the SWA. To change your last known address send a separate written notification that includes the new information to the SWA. Enter your name the company business name employer identification number EIN and your street address or post office box. Do not enter your representative s address or post office box. Note The EIN number must be a tax- identification number that is registered in the SWA in the state where the employer s business is located and WOTC certification requests are submitted so that the SWA may verify if a WOTC applicant is a rehire and establish an employer-employee relationship where wages are paid and federal taxes deducted in the state. Employers should verify with the SWA that the appropriate EIN is provided consistently across IRS Form 8850 and ETA Forms 9198 and or 9061. Do not enter any information pertaining to the employer s representative if any in this section. Line 2. Representative s Information Enter the full name and mailing address of the company representing the employer. Use the identical full name on all submissions and correspondence. You may not designate more than two 2 representatives on Form 9198 or on a substitute form accepted by the SWA to receive copies of WOTC notices and communications sent to the employer unless the SWA allows additional representatives to be sent copies of notices and communications. If naming more than two representatives write See attached for additional representatives in the space to the right of line 2 and attach an additional page 1 of Form 9198. If you want to authorize your representative s to receive copies of notices and communications sent by the SWA you must check the box provided under the representative s name and address. Note Employers may check with the SWA for the maximum number of employer representatives that can be authorized per company. Do not check the box if you do not want copies of WOTC notices and communications sent to your representative s . Substituting or adding a representative. Your representative may substitute or add another representative within the same company unless this Act is prohibited by the employer as indicated in Line 3 Acts. Authorized. Line 3. Acts Authorized This authorization is for the representative to sign their name on IRS Form 8850 and related ETA processing forms. This is not an authorization for the representative to sign the IRS and or ETA WOTC forms with the employer s name. This authorization grants authority for the authorized representative s to Substitute or add representative s within the same company. Representation only applies for the years or periods listed on Line 3 Acts Authorized. The employer s signature date is the effective date of this authorization. You may not list any years or periods that have already ended as of the date the employer signs the form. Enter the year s or period s the authorization is valid using the MM DD YYYY format. Do not use a general reference such as All years or All periods. The SWA will return any Declaration with a general reference. Note The authorization will automatically terminate five 5 years from the date signed by the Employer unless revoked or withdrawn earlier by either party. For Privacy Act and Paperwork Reduction Act Notice see the instructions. ETA Form 9198 May 2023 U.S. Department of Labor Employment and Training Administration Line 4. Retention Revocation of Prior Authorizations When the SWA receives this Employer Authorization Declaration Form it will generally revoke any earlier authorization s previously submitted by the Employer for the same matter unless specified on Line 4. If you do not want to revoke any existing authorizations check the box on Line 4 and attach a copy of the authorization s . Part II. Declaration of Representative Line 5. Employer Declaration and Signature You must sign and date the Declaration. Digital electronic or typed-font signatures must meet the system requirements for electronic signatures defined in IRS Ann. 2002-44 2002-1 C.B. 809. See Electronic Signatures earlier . Line 6. Representative Declaration and Signature The representative must sign and date the Declaration. The representative must handwrite their signature on Form 9198 if the employer will file it on paper or by fax. Digital electronic or typed-font signatures must meet the system requirements for electronic signatures defined in IRS Ann. 2002-44 2002-1 C.B. 809. See Electronic Signatures earlier . If the employer will use an electronic signature the employer representative may also sign Form 9198 electronically. Note Generally the employer signs first granting the authority and then the representative signs accepting the authority granted. In this situation for domestic authorizations the representative must sign within 45 days from the date the employer signed 60 days for authorizations from employers residing abroad . If the representative signs first the employer does not have a required time limit for signing. Privacy Act and Paperwork Reduction Act Notice. Form 9198 is provided by the DOL for your convenience and its use is voluntary. If you choose to designate a representative to act on your behalf for WOTC purposes you must provide the requested information. The SWA will use this information to properly identify you employer and your designated representative and determine the extent of the representative s authority. Failure to provide the information requested may delay or prevent honoring your Employer Representative designation. You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Persons are not required to respond to this collection of information unless it displays a currently valid OMB Control Number. Public reporting burden for this collection of information is estimated to average 30 minutes per response including the time for reading instructions gathering the information needed completing and reviewing the form and submitting the form to the local SWA. 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 . Do not send Form 9198 to the Department of Labor. Instead send Form 9198 to the State Workforce Agency SWA . See How To File earlier. U.S. Department of Labor Employment and Training Administration ETA Form 9065 Rev. M ay 2023 OMB Control No. 1205-0371 Expiration Date May 31 2026 Page 1 of 2 Work Opportunity Tax Credit Audit Summary Worksheet For State Workforce Agency SWA Internal Use Only 1. NAME OF JOB APPLICANT NEW HIRE Last First Middle Initial 2.APPLICANT S SOCIAL SECURITY NUMBER 3. EMPLOYER S NAME TELEPHONE NUMBER AND ADDRESS THE SECTION BELOW IS TO BE COMPLETED BY THE SWA CERTIFYING AGENCY ONLY 4. CERTIFYING AGENCY Check one Conditional Certification was issued by Participating Agency PA St ate Workforce Agency 5. DATE CERTIFIED mm dd yyyy 6. SOURCES USED TO DOCUMENT APPLICANT S NEW HIRE S TARGETED GROUP ELIGIBILITY List all documentation provided 7. AUDIT SAMPLE RESULTS Complete ONLY if selected as part of RANDOM SAMPLE in a quarterly audit a. I have reviewed contacted the source s indicated in box 6 and have confirmed that the certified individual is ELIGIBLE. b. I have reviewed contacted the source s indicated in box 6 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 SWA REVIEWER Type or Print 9.CERTIFYING OFFICER S SIGNATURE 10. DATE Persons are not required to respond to this collection of information unless it displays a valid OMB Control Number. Respondents 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 Washington D.C. 20210 Paperwork Reduction Act - OMB 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 9065 Rev. May 2023 AUDIT SUMMARY WORKSHEET ETA FORM 9065 INSTRUCTIONS. 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 . Section 261 f 2 of the Economic Recovery Tax Act of 1981 P.L. 97-34 states that A 5 000 000 shall be used to test whether individuals certified as members of targeted groups under section 51 of 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. Verification activities require testing the validity of all Certifications issued by the SWAs including Conditional Certifications issued by Participating Agencies. A General Accounting Office GAO report recommended that verification activities be completed by an employee other than the person who originally processed the Individual Characteristics Form ETA Form 9061 or Conditional Certification ETA Form 9062 . DEFINITIONS 1. Quality Review - ETA recommends SWAs conduct a review of each certification request WOTC Processing Forms supporting documentation and Employer Certifications issued as a quality control method. During the initial review the SWA should determine if the certification request IRS Form 8850 was timely filed and complete. Quality reviews are part of the SWAs administrative responsibilities to ensure the required information for employers certification requests is complete and accurately recorded. 2.Audit - To reduce the chances of erroneously certifying ineligible persons for WOTC SWAs must conduct quarterly audits. A quarterly audit is a verification activity to examine the quality of the SWA s certification process. If the SWA issued an incorrect Certification the SWA must revoke the Certification. For those applications found to be ineligible the SWA must issue a notice of invalidation NOI or notice of revocation NOR based on the review of Certifications supporting documentation. INSTRUCTIONS FOR COMPLETING THE AUDIT SUMMARY WORKSHEET ETA FORM 9065 OPTIONAL This worksheet is an optional Form for SWAs internal use in recording the results of verification activities conducted by the SWA. States are not required to submit this Form to ETA. The Form s design and format are optional states can change the design and format to meet their reporting needs. Box 1. Name of Individual. Enter the full name last first and middle initial of the individual certified as a targeted group member. Box 2. Social Security Number. Enter the individual s applicant s 9-digit social security number. Box 3. Employer Name Telephone No. Address. Enter the employer s name address including zip code and telephone number. Box 4. Certifying Agency. Enter name of SWA issuing the Employer Certification. Indicate with a checkmark whether the CC was issued by a Participating Agency PA or a SWA. Box 5. Date Certified. Enter month day and year when the Certification was issued by the SWA. Box 6. Documentary Sources. List and or describe the documentary evidence or sources of collateral contacts that were attached to the certification request IRS Form 8850 and or Individual Characteristics Form ETA Form 9061 . Box7. Audit Sample Results. Upon review of documentation during the audit indicate with a checkmark if the individual is eligible ineligible or eligibility cannot be determined. Follow the instructions below based on the audit outcomes a.If review of documentation reveals that the certified individual is eligible enter a checkmark by eligible. b. If review of documentation reveals that the certified individual is ineligible explain why. If review reveals that the SWA has not been able to establish eligibility provide the reason. For UConditional Certifications CCs U prepare and send the following notices Notification of Invalidation NOI - The NOI notifies the Participating Agency PA job applicant and employer seeking Certification that the Conditional Certification CC is INVALID due to missing or incorrect information items. Copies of the NOI should be sent to the applicant PA authorized official and employer authorized representative where appropriate . Notice of Revocation NOR - The NOR should communicate to the employer the reason why the SWA was not able to determine that the employee is a member of a targeted group and the effective date of the revocation. The NOR should also inform affected employers that wages paid to the non-eligible employee cannot continue to be treated as qualified wages for WOTC purposes. SWAs should send the NOR to the employer authorized representative where appropriate and the IRS. SWAs can transmit the NOR to IRS at the following IRS fax number Inter nal Revenue Service Small Business Self-Employed Campus Compliance Services Fax 1-855-242-6540 Box 8. Name and Title of Reviewer. Enter full name and title of authorized SWA staff conducting audit review. Box 9. Signature. Enter signature of authorized reviewer conducting audit. Box 10. Date. Enter date mm dd yyyy when audit was conducted by SWA. P age 1of 5 V U.S. Department Labor Employment and Training Administration ETA Form 9058 Rev. May 2023 OMB Control No. 1205-0371 Expiration Date May 31 2026 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 Act OMB Control No. 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 F1. F2 . F3.G Incomp lete Requests H Requests Needing Action PART II. CHARACTERISTICS OF CERT IFIED INDIVIDUALS I By WOTC Targeted Group 1. IV-A TANF Recipient 2Ba. Veteran Receiving SNAP Benefits V 2Bb. Disabled Veteran DV 2Bc. DV Unemployed for 6 mos 2Bd. V Unemployed for 4 weeks 2Be. V Unemployed for 6 mos 3. Ex-Felon 4. Summer Youth Employee 5. Designated Community Resident 6a. Voc. Rehab VR Referral 6b. Ticket Holder Ticket to Work 7. SNAP Recipient 8. SSI Recipient 9. Long-Term TANF Recipient 10. LTUR 11. TOTAL For Qtr 12. TOTAL YTD a No . of CCs Resulting In Certifications b No. of Ce rtified Individuals J By Occupation Name Code No. 1. Management Occupations 11 2. Business Financial Operations 13 3. Computer Mathematical 15 4. Architecture Engineering 17 5. Life Physical Social Sciences 19 6. Community Social Services 21 7. Legal Occupations 23 8. Education Training Library 25 9. Arts Design Entertainment Sports Media Occupations 27 10. Healthcare Practitioner Technical 29 11. Healthcare Support Occupations 31 a No. of Certified Individuals J By Occupation C ont. Name Code No. 12. Protective Services 33 13. Food Preparation Serving 35 14. Building Grounds Cleaning Maintenance 37 15. Personal Care Service - 39 16. Sales Related Occupations 41 17. Office Administrative Support 43 18. Farming Fishing Forestry 45 19. Construction Extraction 47 20. Installation Maintenance Repair 49 21. Production Occupations 51 22. Transportation Material Moving Production Occupations 53 23. Military Specific Occupations 55 24. TOTAL For Qtr a No. of Certified Individuals K By Starting H ourly Wage Under Federal Minimum Wage 1. 2. At Federal Minimum Wage 3. 7.25 - 9.99 4. 10.00 - 14.99 5. 15.00 - 19.99 6. 20.00 - more 7. TOTAL For Qtr a No. of Certified Individuals 25. Name and Title of Certifying Official 26. Signature 27. Date Page 2 of 5 ETA Form 9058 Rev. Ma y 2023 U.S. Department of Labor Employment and Training Administration Instructions for Preparing Certification Workload and Characteristics of Certified Individuals ETA Form 9058 Report 1 Work Opportunity Tax Credit Introduction. Part I. of t his 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 w ill report on two new metrics in the EBSS tax credit reporting system 1 Out-of- state certification requests received during the reporting period fiscal quarter and 2 Reason for issuing Denial notifications. See Part I. Certification Workload Item C and Item F. Thi s form also contains updated wage bracket information for reporting on new hire hourly wages . S ee Part II. Section K By Starting Hourly Wage. 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 . U.S. Department of Labor Employment and Training Administration 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 9 30 23 . Pa rt 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 verificatio n r equests from other SWAs for individuals who reside and possibly receive public welfare benefits in their state although the employer s business is located in another state per information provided on IRS Form 8850 . 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 . This number should b e i ncluded in the value entered for Item C New Requests. It is Important for SWAs to report all certification requests IRS Form 8850s received. Therefore any requests that were received outside of the current report ing quar ter which have not been previously recorded reported on a prior ETA Form 9058 should be included in t he c ount 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 endi ng dat e. 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. F 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 thru F3 categories defined below. Note A Denial is a request IRS Form 8850 determined to be ineligible for the WOTC by the SWA. F1. Enter the total number of Denials issued due to failure to meet IRS Form 8850 timely-submission requirement. This number should be reflected in the total value entered for Item F Denied Requests. F2. Enter the total number of Denials issued due to applicant does not meet targeted group s eligibility requirements. This number should be reflected in the total value entered for Item F Denied Requests. F3. Enter the total number of Denials issued due to ineligible rehires applicant previously worked for the employer seeking WOTC certification . This number should be reflected in the total value entered for Item F Denied Requests. G 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. 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 i s a uto-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 ET A F orm 9058. U.S. Department of Labor Employment and Training Administration 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. S ection 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. Se ction 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. Se ction 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. By Starting Hourly Wage 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. U.S. Department of Labor Employment and Training Administration Section I Line 12. After Quarter 1 for all subs equent quarters enter the cumulative fiscal Year-to-Date YTD totals of columns a and b . Reminder 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. USection 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 24 is the sum of the column and must equal the total for Section I Columns a b Line 11 TOTAL For Qtr . 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. 24. TOTAL For Qtr . Enter the total number of certifications issued for the current reporting period quarter . O NET SOC JOB FAMILIES Occupation Name Code Management Occupations 11 Business Financial Occupations 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 7 is the sum for that quarter and must be equal to the total for Section I Column b Line 11 Number of Certified Individuals. 31TUFederal Minimum Wage information U3 1T. Convert annual earnings to hourly wages as follows Unit of Time Calculated Hourly Wage Day W eek Month Amount divided by 8 Amount divided by 40 Amount divided by 172 25. Name and Title of Certifying Official. Enter the name and title of the authoriz ed signatory official. 26. Signature. Enter the signature of the authorized s ignatory official. 27. Date. Enter the date of signature.