Form 9061 - Individual Characteristics Form Work Opportunity Tax Credit - U.s. Department Of Labor

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Individual Characteristics Form
U.S. Department of Labor
Work Opportunity Tax Credit
Employment & Training Administration
Individual Information
1. CONTROL NO.
OMB No. 1205-0371 Expires: 8/31/09
(For Agency Use Only)
(Instructions on the Back)
2. DATE RECEIVED
(For Agency Use Only)
3. EMPLOYER NAME/ADDRESS:
4. EMPLOYER FEDERAL ID NO.
5. EMPLOYMENT START DATE::
Starting Wage:
6. Have you worked for the above
employer before?
$_________________
per hour
Yes_____ No_____
POSITION:
If Yes, enter date and year: _____________
7. NAME OF INDIVIDUAL
(Last, First, Middle):
8. SOCIAL SECURITY NUMBER:
The above named individual is determined to have the following characteristics for WOTC target group certification:
9. Is your age between 18 but not age 40 or older?
10. Is a veteran and a member of a
11. Is a member of a family that received
family that received Food Stamps for a period of
TANF benefits for any 9 months in the last 18
at least 3 months in the last 15 months.
months.
Yes_____
No_____
Yes_____ No_____
Yes_______
No_______
If YES, also complete Box 17.
If YES, also complete Box 17.
If YES, indicate your "Date of Birth" below:
Date of Birth: ______________________
12. Is a member of a family that received Food
13. In the past year, individual has been
14. Lives and plans to continue living in
Stamps for the last 6 months.
convicted of a felony or released
a federal Empowerment Zone,
from prison after a felony conviction.
Enterprise Round II or Renewal Community.
Yes_______ No________ , or
Yes______ No_______
.
for at least a 3-
month period within the Iast 5 months,
Yes ________ No ____
If YES, complete below:
BUT is no longer receiving them.
______________________________________
16. Received Supplemental Security Income
Date of Conviction _______________
(SSI) benefits for any month ending within the last
Yes_______ No______
60 days.
Date of Release ________________
Yes_________ No_______
If YES to either, also complete Box 17.
15. Is receiving or has received Rehabilitation
17. If individual is not a primary recipient of
Services through a State Rehabilitation Services’
benefits, please provide the following:
program or the Veterans' Administration.
_____________________________________
Yes_______ No________
Name of Primary Recipient
_____________________________________
City/State of Benefits
18. Is a “ticket holder” under the Ticket to Work Program
19. The “ticket holder” has an Individual Work Plan (IWP) from an Employment
Network (EN).
Yes _________ No _________
Yes _________ No _________
20. Is a member of a family that::
• Has received/is receiving TANF payments for at least the last 18 consecutive months;
Yes ____ No ____ or
• Has received/is receiving TANF payments for any 18 months starting after August 5, 1997;
and the earliest 18-month period beginning after August 5, 1997, and ended within the last 2 years; or Yes ______No
or
• Stopped being eligible for TANF payments within the last 2 years because Federal or state law
Yes _____ No ____
limited the maximum time those payments could be made, and having a hiring date not more than 2 years after the date of cessation of TANF benefits.
21. 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. If applicant is a minor, the parent or guardian should sign this box.
22. SIGNATURE:
23. DATE:
Page 1 of 3
ETA Form 9061 (Rev. Dec. 2006)

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