Eta Form 9062 - Work Opportunity Tax Credit - 2007

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Conditional Certification
U. S. Department of Labor
Work Opportunity Tax Credit
Employment & Training Administration
OMB No. 1205-0371
Expiration Date: April 30, 2008
1. INITIATING AGENCY CODE
2. CONTROL NO
3. TYPE OF CONDITIONAL CERT.
(For Agency
. (For Agency Use
Use Only)
Only)
(“ ” One)
CONTROL NO.
_______________
(For Summer Youth ONLY)
CODE: ___________
____ Participating Agency
a.
Original
b.
Revalidation
____ SWA/DLA
4. FOR EX-FELON TARGET GROUP ONLY.
5. DATE COMPLETED
(Mo/Day/ Yr)
a. Conviction Date: _________________
b. Release Date: __________________________
_________________
c. Corrections Institution ID No:_________________
6. State Workforce Agency’s Name and Address
7. SIGNATURE (Authorized Official)
8. TELEPHONE NO.
PART I. INTRODUCTION
9. NAME OF INDIVIDUAL (Last, First, Middle)
10. SOCIAL SECUIRTY NO.
11. TARGET GROUP CODE (“ ” One)
Disabled Veteran receiving compensation
for a service-connected disability.
12. ADDRESS (Number, Street, City, State, Zip Code)
13. TARGET GROUP CODE (“ ” One)
Ticket Holder (TH) with IWP from an Employment Network,
Summer Youth (SY),
Long-Term Family Assistance Recipient (LTFAR), or
Designated Community Resident (DCR). If DCR, enter name of
RRC in the blank: ___________________________________
Name of County
Enter Code if not a TH, SY, LTFAR:, or DCR _______________
14. APPLICANT’ SIGNATURE:
NOTE TO EMPLOYER:
15. The above named individual may be eligible for
In the event you hire this person, you should request the certification
certification under the Work Opportunity Tax Credit. If
necessary for you to claim a Work Opportunity Tax Credit. Simply,
not employed before the date in the box below (Mo.,
complete and sign the Employer Declaration below, mail to the SWA or
Day, Yr.), this eligibility determination is subject to
Designated Local Agency together with the PSN-IRS Form 8850, not
th
review.
later than the 28
day after the applicant starts work. The WOTC
Employer Certification Form will be sent to you, if all statutory requirements
have been met.
PART II. EMPLOYER DECLARATION: I, HEREBY, DECLARE that the above named person is or will be employed by:
I, HEREBY, DECLARE that the above named person was or will be employed by:
16. NAME OF FIRM:
17. POSITON/JOB TITLE:
18. EMPLOYMENT-START
19. STARTING
WAGE:
DATE
: (Mo/Day/Yr)
$ _________ per
hour.
Please send a WOTC
Conditional Certification (CC) for this employee. The pre-certification is for the purpose of requesting
Certification to obtain the WOTC under Sec. 51 of the Internal Revenue Code. Employers are advised that such credit will cease
immediately upon notification of any subsequent invalidation/revocation. Employers are further advised that if the certification herein
requested is for a member of the SUMMER YOUTH target group, the tax credit for which he/she may be eligible is subject to the
limits described at Sec. 51 (d)(7) of the Internal Revenue Code.
NOTE: Falsification of data on this form is a FEDERAL CRIME in violation of 18 USC 1001. Falsification of work or
concealment of information is PUNISHABLE by a fine or imprisonment.
21. DATE
20. EMPLOYER’S NAME AND SIGNATURE
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ETA Form 9062 (Rev. June 2007)

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