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CONDITIONAL CERTIFICATION (CC) ETA FORM 9062. When a SWA or participating agency (PA) determines that a job-ready applicant is,

tentatively, ELIGIBLE as a member of a target group under WOTC, it shall use this required form, without modification, to show that an eligibility pre-

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 individual is hired, and provides a means for employers to request a WOTC certification for this person.

INSTRUCTIONS FOR COMPLETING THE “CONDITIONAL CERTIFICATION” FORM. (Boxes 1-8 and 15 are for participating agency (PA)

and SWA use only)

Box 1:

Initiating Agency Code. If the CC was issued by a Participating Agency (PA), enter its code. SWAs 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, enter the SWA’s code, if available. Indicate with a check mark “” if initiating agency is a PA or SWA.

Box 2:

Control Number. Usually the PA determines the control number (CN). However, SWAs may, for internal control purposes, develop their

own CN system. It may be a case number or some other appropriate designation (e.g., alpha-numeric 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.

Box 3:

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

verifying target group eligibility.

Box 4:

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

Box 5:

SWA’s Name and Address. If known, enter or stamp the name and address, including zip code, of the SWA responsible for Certification

requests for the employer indicated in Box 15. Leave blank if SWA’s name and address is unknown.

Box 6:

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

Box 7:

Telephone No. Enter corresponding SWA or PA area code, telephone number and extension, if available.

PART I.

APPLICANT’S INFORMATION AND CONDITIONAL CERTIFICATION (CC):

Box 8:

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

Box 19:

Social Security Number. Enter the individual’s/applicant’s Social Security Number.

Box 10:

Target Group Code. Enter the code or name of the pre-certified non-veteran target group. The non-veteran groups and the Empowerment

Zones were retroactively reauthorized through December 31, 2013 by the American Taxpayer Relief Act of 2013 signed into law by

President Obama on January 2, 2013. This Act also authorized the continuation of the VOW Act expanded veteran groups and

provisions through December 31, 2013.

Box 11:

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

individual’s telephone number, including area code.

Box 12: Veteran Target Group Code. The 1996 original target group designation for a Qualified Veteran is “B.” To facilitate the identification of the

different veteran categories created by the VOW to Hire Heroes Act of 2011 (P.L. 112-56,), ETA is using the same alpha-numeric

designations used to collect the number of certifications issued for the amended veteran categories in ETA Form 9058 – Report 1. To

ensure a simple, uniform and consistent certification system which can be used by the SWAs nationwide each new veteran category is

preceded by “B” and followed by the alpha-numeric code used in ETA Form 9058. Enter a check mark “” in front of the veteran

group pre-certified.

Box 13: Signature. Get applicant’s signature. If a minor, parent or guardian must sign here.

Box 14:

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

This box only applies to the Summer Youth group.

Box 15:

Name of Firm. Enter full name of the employing firm (the firm where the employee will actually work) and the address.

Box 16:

Position/Job Title. Enter the position or job title the employee will hold.

Box 17:

Employment-Start Date. Enter the date the employee began or will begin work for the employing firm.

Page 2 of 3

ETA Form 9062 (Rev. August 2015)

Eta Form 9062 (Rev. August 2015) - Conditional Certification Work Opportunity Tax Credit Page 2

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