Form Eta-9061 - Individual Characteristics Form Work Opportunity Tax Credit And Welfare-To-Work Tax Credit 1998

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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)
Expires: 06/30/2001
(Instructions on the Back)
2.
DATE RECEIVED
(For Agency Use Only)
4.
EMPLOYER ID NUMBER
3.
EMPLOYER NAME/ADDRESS
5.
EMPLOYMENT START DATE
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 to have the following characteristics for WOTC Target Group Certification:
9.
Age between 16 - 25?
10. A veteran and a member of a
11. Is a member of a family that received
family that received Food Stamps for a
AFDC (TANF) benefits for any 9 months in the
Yes ______
No ______
period of at least 3 months in the last 15
last 18 months.
months.
If YES, indicate your “Date of Birth” below:
Yes ______
No ______
Yes ______
No ______
Date of Birth
If YES, also complete Box 17.
If YES, also complete Box 17.
14.
Lives and plans to continue living in a
12. Is a member of a family that received Food
13. In the past year has been convicted
Federal Empowerment Zone or Enterprise
Stamps for the last 6 months.
of a felony or released from prison after a
Community.
felony conviction.
Yes ______
No ______
or
Yes ______
No ______
Yes ______
No ______
for at least a 3-month period within the last 5 months,
BUT is no longer receiving them?
If YES, complete below:
16.
Received Supplemental Security
Yes ______
No ______
Date of Conviction ________________
Income (SSI) benefits for any month ending
within the last 60 days.
If YES to either, also complete Box 17.
Date of Release __________________
Yes ______
No ______
Total Income for the past 6 months for all
family members living in the same
household?
17. If individual is not a primary recipient of
15. Is receiving or has received Rehabilitation
Total Income: ____________________
benefits, please provide the following:
Services through a State Rehabilitation Services
program or the Veterans’ Administration.
(If No Income, Enter 0 above)
_____________________________________
No. of family members living in the same
Name of Primary Recipient
Yes ______
No ______
household for the past 6 months including
_____________________________________
yourself: _________________
City/State of Benefits
This section 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. 4 (12-98) (INTERNET)
Page 1 of 3
ETA-9061 (Rev. Jan. 1998)

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