Attachment IV - ETA Form 9198 - Employer Representative Declaration Form.pdf

ETA Advisory File Text

---- ------------------ ---- U.S. Department of Labor Employment and Training Administration 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 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 R eceiving copies of notices or communications related to an employer s certification request S ubstitute 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. R etention Revocation of Prior Authorization. The filing of this Employer Representative Declaratio n Fo rm 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. Em ployer 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. E mployer Signature Date Printed Name Relationship to Employer Self Other Signatory Title Company Name 6 . R epresentative 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 Admin istration 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-party submitting Form 9198 to the SWA on behalf of the employer must attest that he or she has authenticated the employer s identity unless the third party has personal knowledge allowing the third party to authenticate the employer s identity. For example through 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 employer is electronically signing the form and the third-party submitter isn t physically present with the employer. Authority Granted Except as specified below or in other ETA guidance this Employer Representative Declaration Form authorizes the listed representative s to perform acts that you can perform with respect to the facilitation of WOTC certification requests described in the Declaration. Representatives are not authorized to inspect and or receive the employer s confidential tax information or to perform any acts i.e. sign agreements or other documents not described in the Declaration. Representative Address ChangeIf the Representative s address has changed the SWA will not require a new Form 9198 to update the new address. The employer or representative can send a written notification that includes 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 Ma y 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 prev iously 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 R epresentative . If your representative wants to withdraw from representation they must wr ite 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 lo cated 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 withdrawa l that indicates the authority of the Declaration is withdrawn lists the matters and years periods and lists the name employer identification n umber EIN and address if known of the Employe r. 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 representati ve 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 employe r 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 representative s 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 au thority 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 sign s 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.