Eta Form 9061 - Work Opportunity Tax Credit (Page 2 of 4) in pdf

Eta Form 9061 - Work Opportunity Tax Credit Page 2

16. Are you a member of a family that received TANF assistance for at least the last 18 months

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 a Rural Renewal County or Empowerment Zone?

Yes__ No __

19. Do you live in an Empowerment Zone and are at least age 16, but not yet 18, on your hiring date? Yes __No __

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__

23. Sources used to document eligibility:

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

SWAs: 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.

24(a). Signature: (See instructions in Box 24.(b) for who signs this

24. (b) Signatory Options: Indicate

25. Date:

with a  mark who signed this form:

signature block)

 Employer,  Consultant,  SWA,

 Participating Agency,  Applicant, or

 Parent/Guardian (if applicant is a

minor)

ETA Form 9061 – (Rev. July 2013)

Eta Form 9061 - Work Opportunity Tax Credit Page 2

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