Eta Form 9062 - Work Opportunity Tax Credit

CONDITIONAL CERTIFICATION (CC) ETA FORM 9062. When a SWA/DLA or Participating Agency (PA) determines that a job-

ready applicant is, tentatively, ELIGIBLE as a member of a target group under the consolidated WOTC, it shall use this required form,

without modification, to show that an eligibility determination was made for this person. Note. The CC serves as an official record of

the pre-certification, alerts prospective employers to the availability of the tax credit if this person is hired, and provides a means for

employers to request a WOTC certification for this person.

INSTRUCTIONS FOR COMPLETING THE “CONDITIONAL CERTIFICATION” FORM. (Boxes 1-15 are for participating

agency and SWA/DLA use only)

Box 1:

Initiating Agency Code. If the CC was issued by a participating agency (PA), enter its code. SWAs/DLAs assign codes

to designate each PA and indicate the initiating source for the eligibility determination process. If the eligibility

determination was performed by the SWA/DLA, enter the SWA/DLA code, if available. Indicate with a check mark “ ” if

initiating agency is a Participating Agency or SWA/DLA.

Box 2:

Control Number. Usually the PA determines the control number (CN). However, SWAs/DLAs may, for internal control

purposes, develop their own CN system. It may be a Social Security No., case no., or some other appropriate designation, which

permits easy filing, certification and retrieval of forms. Enter corresponding CN and indicate with a check mark “ ” whether the

source is a PA or a SWA/DLA.

Box 3:

Type of Conditional Certification. This system distinguishes between “Original,” if the individual is being processed for the first

time, or “Revalidation,” if the eligibility process was performed within the previous 12-month period, (e.g. , 45 days for the Summer

Youth target group only). Otherwise, the Conditional Certification is counted as “Original.” Indicate with a check mark “ ” whether

eligibility determination is “Original” or “Revalidation.”

Box 4:

For Ex-Felon Target Group Only. For items a - c, enter the corresponding information. This information will help you in

verifying target group eligibility.

Box 5:

Date Completed. Enter the month, day, year in which the eligibility determination was completed.

Box 6:

SWA/DLA’s Name and Address. (If known, enter or stamp the name and address, including zip code, of the SWA/DLA

responsible for Certifications requests for the employer indicated in Box 16. Leave blank if SWA/DLA’s name and address is

unknown.

Box 7:

Signature. Enter signature of the authorized conditionally-certifying official.

Box 8:

Telephone No. Enter corresponding SWA/DLA or participating agency area code, telephone number and extension, if available.

PART I.

INTRODUCTION:

Box 9:

Name of Individual. Enter the individual’s/applicant’s full name (i.e., last name, first name and middle initial).

Box 10:

Social Security Number. Enter the individual’s/applicant social security number.

Box 11:

Target Group Code. Enter a check mark “ ” to indicate if individual is being pre-certified as a Disabled Veteran according to

P.L. 110-28.

Box 12:

Address/Telephone No. Enter the individual’s/applicant’s home address, including apartment number and zip code. After

address, enter individual’s/applicant’s telephone number, including area code.

Box 13: Target Group Code. Enter a check mark “ ” to indicate if “Summer Youth, “Ticket Holder (TH)” with an IWP from an

Employment Network (EN) , Long-term Family Assistance Recipient (LTFAR), or Designated Community Resident (DCR). If a

DCR living in RRC, enter name of county on the blank space. If different from Summer Youth, Ticket Holder, LTFAR, or DCR,

enter code for specific WOTC target group based on applicant’s information and available documentation.

Box 14: Signature. Get applicant’s signature. If a minor, parent or guardian must sign here.

Box 15:

CC Validity Period. (This box is to be completed by the SWA/DLA or PA). Enter the month/day/year when the CC expires

(e.g., 45 days for Summer Youth)

Page 2 of 3

ETA Form 9062 (Rev. June 2007)

Eta Form 9062 - Work Opportunity Tax Credit - 2007 Page 2

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