De 8725 Form - Individual Characteristics Form Work Opportunity Tax Credit

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Individual Characteristics Form
U.S. Department of Labor
Work Opportunity Tax Credit and
Employment and Training Administration
Welfare-to-Work Tax Credit
U.S. Employment Service
1.
CONTROL NO.
Individual Information
OMB Control No.: 1205-0371
(For Agency Use Only)
(Instructions on the Back)
Expires: 03/31/98
2.
DATE RECEIVED
(For Agency Use Only)
5.
EMPLOYMENT START DATE
3.
EMPLOYER NAME/ADDRESS
4.
EMPLOYER ID NO.
Starting Wage:
6. Have you worked for the above
$________________ per hour
employer before?
POSITION:
Yes ______
No _______
8. SOCIAL SECURITY NUMBER:
7. NAME OF INDIVIDUAL (Last, First, Middle)
The above named individual is determined as having the following characteristics for WOTC Target Group and Welfare-to-Work Credit Certification.
9.
Is your age between 16 - 25?
10. Is a veteran and a member of a
family that received Food Stamps for a
Yes ______
No ______
period of at least 3 months in the last 15
months.
If YES, indicate your “Date of Birth” below:
Yes ______
No ______
Date of Birth
If YES, also complete Box 16.
11. Is a member of a family that received AFDC
12. Is a member of a family that received
13. In the past year has been convicted
Food Stamps for the last 6 months.
of a felony or released from prison after a
(TANF) benefits for any 9 months in the last 18 months.
felony conviction.
Yes ______
No ______
or
Yes ______
No ______
Yes ______
No ______
If YES, also complete Box 16.
If YES, also complete Box 16.
If NO, SKIP to Box 14.
for at least a consecutive 3-month period
within the last 5 months, BUT is no longer
Date of Conviction _______________
receiving them.
Date of Release __________________
Yes ______
No ______
Total Income for the past 6 months for all
If YES, also complete Box 16.
family members living in the same
household?
15. Is receiving or has received Rehabilitation
14.
Lives and plans to continue living in a Federal
Total Income: ____________________
Services through a State Rehabilitation Services
Empowerment Zone or Enterprise Community.
program or the Veterans’ Administration.
(If No Income, Enter 0 above)
Yes ______
No ______
No. of family members living in the same
Yes ______
No ______
household for the past 6 months, including
yourself: _____________
16. If individual is not a primary recipient of benefits,
17. Received Supplemental Security Income (SSI) benefits for any month ending within the
please provide the following:
last 60 days.
_______________________________________________
Yes
No
Name of Primary Recipient
_______________________________________________
City/State of Benefits
The following box is to be completed by individuals starting work after December 31, 1997, under the Welfare-to-Work Tax Credit only.
18. Is a member of a family that:
Has received AFDC or TANF payments for at least the last 18 consecutive months:
Yes
No
or
Has received/is receiving AFDC or TANF payments for any 18 months starting after August 5, 1997:
Yes
No
or
Stopped being eligible for AFDC or TANF payments after August 5, 1997 because Federal or state law
Yes
No
limited the maximum time such assistance is payable.
19. SOURCES USED TO DOCUMENT ELIGIBILITY:
Note: I certify that the information is true and correct to the best of my knowledge. I understand that the information above may be subject to verification.
The signature of the party completing this form is required below.
20. SIGNATURE
21.
DATE
DE 8725 Rev. 2 (11-97) (INTERNET)
Page 1 of 2
ETA-9061 (Sept 1997)

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