Eta Form 9061 - Individual Characteristics Form (Icf) Work Opportunity Tax Credit (Page 2 of 2) in pdf

before you were hired?

Yes___ No___

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?

Yes___ No___

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?

Yes___No___

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?

Yes___No___

If YES, to any question, enter name of primary recipient ________________________ and

the city and state where benefits were received _________________________.

17. Were you convicted of a felony or released from prison after a felony conviction during

the year before you were hired?

Yes___No___

If YES, enter date of conviction ________________ and date of release _________________.

Was this a Federal ____ or a State conviction_____? (Check one)

18. Do you live in an Empowerment Zone or Rural Renewal County (RRC)?

Yes__ No __

19. Do you live in an Empowerment Zone and are at least age 16, but not yet 18, on

Yes __ No __

your hiring date?

20. Did you receive Supplemental Security Income (SSI) benefits for any month ending within

60 days before you were hired?

Yes__ No__

21. Are you a veteran unemployed for a combined period of at least 6 months (whether or not

consecutive) during the year before you were hired?

Yes__ No__

22. Are you a veteran unemployed for a combined period of at least 4 weeks but less than 6 months (whether or not

consecutive) during the year before you were hired?

Yes__ No__

Are you an individual who is or was in a period of unemployment that is at least 27 consecutive weeks

23.

the day before you began to work for the employer, or if earlier, the day you completed IRS Form

8850, the Prescreening Form?

Yes__ No__

If YES, did you receive unemployment compensation/benefits under State or Federal law

during a period of unemployment?

Yes__ No__

24. Sources used to document eligibility:

(Employers/Consultants: List all documentation provided or forthcoming. For

SWA Staff: List all documentation used in determining target group eligibility and enter your initials and date when the

determination was made.

I certify that this information is true and correct to the best of my knowledge. I understand that the

information above may be subject to verification.

25(a). Signature:

25.(b)

Indicate with a  mark who

26. Date:

(See instructions in Box 25.(b) for who signs this

signature block)

signed this form:

 Employer,  Consultant,  SWA,

 Participating Agency,  Applicant, or

 Parent/Guardian (if applicant is a

minor)

ETA Form 9061 (Rev. May 2016)

Eta Form 9061 - Individual Characteristics Form (Icf) Work Opportunity Tax Credit Page 2

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