ETA Advisory File
ETA Advisory
ETA Advisory File Text
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.