Looking for a Eta Form 9062 Templates? Download it for free!

Eta Form 9062 (Rev. August 2015) - Conditional Certification Work Opportunity Tax Credit Page 3

Box 18:

Starting Wage. Enter the wage or salary which the employee will be paid. If not known, enter an estimated wage.

Box 19:

Employer’s Name. Enter your name as the hiring employer.

Box 20: Employer’s Signature. Affix your electronic or ink signature here.

Box 21: Date. Enter month, day and year when you signed this form.

Persons are not required to respond to this collection of information unless it displays a currently valid OMB Control Number. Respondents’

obligation to reply to these questions is required for obtaining the tax credit per P.L. 104-188. Public reporting burden for this collection of

information is estimated to average .33 minutes per response, including the time for reading instruction, searching existing data sources, gathering

and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or

any other aspect of this collection of information, including suggestions for reducing the burden to the U.S. Department of Labor, Employment and

Training Administration, Division of National Programs, Tools, and Technical Assistance, 200 Constitution Ave., NW, Room C-4510, Washington,

D.C. 20210 (Paperwork Reduction Project 1205-0371)

Privacy Act Statement: The Internal Revenue Code of 1986, Section 51, as amended and its enacting legislation, P.L. 104-188,

specify that the State Workforce Agencies are the "designated" agencies responsible for administering the WOTC certification

procedures of this program. The information you have provided completing this form will be disclosed by your employer to the State

Workforce Agency. Provision of this information is voluntary. However the information is required for your employer to receive the

federal tax credit. IF THE INFORMATION YOU PROVIDE IS ABOUT A MEMBER OF YOUR FAMILY, YOU SHOULD PROVIDE

HIM/HER A COPY OF THIS NOTICE

Page 3 of 3

ETA Form 9062 (Rev. August 2015)

Eta Form 9062 (Rev. August 2015) - Conditional Certification Work Opportunity Tax Credit Page 3