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Get Id Employer 2016-2024

Date Employer Consultant SWA Participating Agency Applicant or Parent/Guardian if applicant is a minor INSTRUCTIONS FOR COMPLETING THE INDIVIDUAL CHARACTERISTICS FORM ICF ETA 9061. This form is used together with IRS Form 8850 to help state workforce agencies SWAs determine eligibility for the Work Opportunity Tax Credit WOTC Program. The form may be completed on behalf of the applicant by 1 the employer or employer representative the SWA a participating agency or 2 the applicant directly if a minor the parent or guardian must sign the form and signed Box 24a. by the individual completing the form. This form is required to be used without modification by all employers or their representatives seeking WOTC certification. Every certification request must include an IRS Form 8850 and an ETA Form 9061 or 9062 if a Conditional Certification was issued to the individual pre-certifying the new hire as eligible under the requested target group. Boxes 1 and 2. No No 15. Were you referred to an employer by a Vocational Rehabilitation Agency approved by a State OR by an Employment Network under the Ticket to Work Program OR by the Department of Veterans Affairs ETA Form 9061 Rev. August 2015 OR are you a member of a family that received TANF benefits for any 18 months beginning after August 5 1997 and the earliest 18-month period beginning after August 5 1997 ended within 2 years before you were hired OR did your family stop being eligible for TANF assistance within 2 years before you were hired because a Federal or state law limited the maximum time those payments could be made If NO are you a member of a family that received TANF assistance for any 9 months during the 18-month period before you were hired If YES to any question enter name of primary recipient the city and state where benefits were received. U*S* Department Labor Employment and Training Administration OMB No* 1205-0371 Expiration Date August 31 2018 Individual Characteristics Form ICF Work Opportunity Tax Credit 1. Control No* For Agency use only 2. Date Received For Agency Use only APPLICANT INFORMATION See instructions on reverse 3. Employer Name EMPLOYER INFORMATION 4. Employer Address and Telephone 5. Employer Federal ID Number EIN 6. Applicant Name Last First MI 7. Social Security Number 8. Have you worked for this employer before Yes No If YES enter last date of employment APPLICANT CHARACTERISTICS FOR WOTC TARGET GROUP CERTIFICATION 9. Employment Start Date 10. Starting Wage 12. Are you at least age 16 but under age 40 If YES enter your date of birth 11. Position Yes 13. Are you a Veteran of the U*S* Armed Forces If NO go to Box 14. If YES are you a member of a family that received Supplemental Nutrition Assistance Program SNAP benefits Food Stamps for at least 3 months during the 15 months before you were hired If YES enter name of primary recipient and city and state where benefits were received. OR are you a veteran entitled to compensation for a service-connected disability If YES were you discharged or released from active duty within a year before you were hired Yes OR were you unemployed for a combined period of at least 6 months whether or not consecutive during the year before you were hired 14.

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