ETA Advisory File
ETA Advisory
ETA Advisory File Text
. 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.