Attachment II - ETA Form 9062 - Conditional Certification.pdf

ETA Advisory File Text

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 .