Eta Form 9061 - Individual Characteristics Form (Icf) - Work Opportunity Tax Credit - 2007

Download a blank fillable Eta Form 9061 - Individual Characteristics Form (Icf) - Work Opportunity Tax Credit - 2007 in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Eta Form 9061 - Individual Characteristics Form (Icf) - Work Opportunity Tax Credit - 2007 with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

Individual Characteristics Form (ICF)

U.S. Department of Labor

Work Opportunity Tax Credit

Employment and Training Administration

1. Control Number

OMB No. 1205-0371

(For Agency use only)

Expiration Date:

APPLICANT INFORMATION

2. Date Received

(For Agency Use only)

(See instructions on reverse)

EMPLOYER INFORMATION

3. Employer Name

4. Employer Address and Telephone

5. Employer Federal ID Number (EIN)

APPLICANT INFORMATION

6. Applicant Name (

7. Social Security Number.

8. Have you worked for this employer

Last, First, MI)

before? Yes ____ No ____

If YES, enter date: ______________

APPLICANT CHARACTERISTICS FOR WOTC TARGET GROUP CERTIFICATION

9. Employment Start Date

10. Starting Wage

. Position

12. Are you at least age 16, but under age 40?

Yes ____ No ___ If YES, enter your date of birth _______________________________

13. Are you a Veteran of the U. S. Armed Forces? Yes ____ No ____ If NO, go to Box 14. If YES, are you a member of a family that

received Food Stamps for at least 3 months during the 15 months before you were hired? Yes ____ No ____

If YES, enter name of primary recipient _______________________ and city and state where benefits were received _________________.

OR, are you a veteran entitled to compensation for a service-connected disability?

Yes ____ No ____

If YES, were you discharged or released from active duty within a year before you were hired? Yes ____ No ____

OR, were you unemployed for a combined period of at least 6 months during the year before you were hired? Yes ____ No ____

14. Are you a member of a family that received Food Stamps for the 6 months before you were hired? Yes ____ No ____

OR, received Food Stamps for at least a 3-month period during the 5 months before you were hired and are no longer receiving them?

Yes ____ No ____

If YES to either question, enter name of primary recipient ___________________________ and city and state where benefits were

received _____________________.

15. Were you referred to an employer by a Vocational Rehabilitation Agency approved by a State?

Yes ____ No ____

OR, by an Employment Network under the Ticket to Work Program?

Yes ____ No ____

OR, by the Department of Veterans Affairs?

Yes ____ No ____

16. Are you a member of a family that received TANF assistance for any 9 months during the 18 months before you were hired? Yes ___ No___

If NO, 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 Federal or state law limited the

maximum time those payments could be made?

Yes ___ No ___

If YES, to any question, enter name of primary recipient ________________________________ and 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 _________________________

18. Do you live in an Empowerment Zone or Renewal Community? Yes ____ No ____

OR, in a Rural Renewal County (RRC)? Yes ____ No ____

If YES, enter name of the RRC: _____________________________

19. Did you receive Supplemental Security Income (SSI) benefits for any month ending within 60 days before you were hired?

Yes ____ No ____

20. Sources used to document eligibility:

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.

21. Signature

22. Date

DE 8725 Rev. 6 (5-08)

DE 8725 Rev. 6 (5-08) (INTERNET)

Page 1 of 3

ETA Form 9061 – June 2007