Eta Form 9061 – Fill Out and Use This PDF

The ETA 9061 Form, officially known as the Individual Characteristics Form (ICF), plays a pivotal role in the Employment and Training Administration managed by the U.S. Department of Labor. It serves as a crucial document for employers seeking certification for the Work Opportunity Tax Credit (WOTC), helping state workforce agencies determine applicant eligibility for various target groups under the program. To streamline the process of accessing this tax credit, it's essential to accurately complete and submit this form.

Click the button below to guide you through filling out the ETA 9061 Form and ensure your eligibility for the WOTC benefits.

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Eta Form 9061 PDF Details

The ETA 9061 form, officially recognized as the Individual Characteristics Form (ICF) by the U.S. Department of Labor and governed under the Employment and Training Administration, plays a critical role in the operation of the Work Opportunity Tax Credit (WOTC) Program. This form, bearing the OMB Control Number 1205-0371 and with an expiration date set for March 31, 2023, serves as a detailed questionnaire designed to gather personal and employment-related information from job applicants. It meticulously collects data ranging from an applicant's name and social security number to their employment history, demographic characteristics, and eligibility for certain target groups that qualify employers for tax incentives under the WOTC. Employers or their representatives, state workforce agencies (SWAs), participating agencies, or in some cases, the applicants themselves (for minors, the responsibility falls on the parent or guardian) can complete the form. It contains precise questions relating to the applicant's potential eligibility under various criteria such as veteran status, familial income, receipt of government benefits (SNAP/TANF), conviction history, and residence within empowerment zones among others. Additionally, it mandates the provision of documentary evidence or forthcoming documents to substantiate the claims made in the application process, thereby facilitating the verification and determination process for eligibility in the targeted groups. This form, which must be used as provided without modifications, underscores the intersecting objectives of employment facilitation and tax credit administration, thereby embodying a multifaceted tool for both workforce development and economic policy execution.

Question	Answer
Form Name	Eta Form 9061
Form Length	5 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 15 sec
Other names	labor individual, form irs 8850 form, eta form 9061 fillable form, form characteristics

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U.S. Department Of Labor

OMB Control No. 1205-0371

Employment and Training Administration

Individual Characteristics Form (ICF)

Expiration Date: March 31, 2023

Work Opportunity Tax Credit

1.Control No. (For Agency use only)

2.Date Received (For Agency Use only)

APPLICANT INFORMATION

(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 (Last, First, MI)

7. Social Security Number

Have you worked for this employer

before? Yes

____

If YES, enter last date of

employment: ____________

APPLICANT CHARACTERISTICS FOR WOTC TARGET GROUP CERTIFICATION

9. Employment Start Date

10. Starting Wage

11. Position

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

Yes

___

If YES, enter your date of birth

_____________________

13. Are you a Veteran of the U.S. Armed Forces?

Yes

___

If NO, go to Box 14.

If YES, are you a member of a family that received Supplemental Nutrition Assistance

Program (SNAP) benefits (Food Stamps) for at least 3 months during the 15 months

before you were hired?

Yes

___

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

___

If YES, were you discharged or released from active duty within a year before you were hired?

Yes

___

OR, were you unemployed for a combined period of at least 6 months (whether or not

consecutive) during the year before you were hired?

Yes

___

14. Are you a member of a family that received Supplemental Nutrition Assistance Program

(SNAP) (formerly Food Stamps) benefits for the 6 months before you were hired?

Yes

___

OR, received SNAP benefits for at least a 3-month period within the last 5 months

But you are no longer receiving them?

Yes

___

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

___

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

Yes

___

OR, by the Department of Veterans Affairs?

Yes

___

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

before you were hired?

Yes

___

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

___

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

___

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

___

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

___

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 an Empowerment Zone or Rural Renewal County (RRC)?

Yes

19.

Do you live in an Empowerment Zone and are at least age 16, but not yet 18, on

Yes

your hiring date?

20.

Did you receive Supplemental Security Income (SSI) benefits for any month ending within

60 days before you were hired?

Yes

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

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

23.Are you an individual who is or was in a period of unemployment that is at least 27 consecutive weeks and for all

or part of that period you received unemployment compensation?	Yes__ No	__

If YES, what state did you receive unemployment compensation in? _________________________

(Enter state where UI compensation was received)

24.Sources used to document eligibility: (Employers/Consultants: List all documentation provided or forthcoming. For SWA Staff: 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.

25(a). Signature: (See instructions in Box 25.(b) for who signs this signature block)

25.(b) Indicate with a  mark who signed this form:

Employer,  Consultant,  SWA,

Participating Agency,  Applicant, or

Parent/Guardian (if applicant is a minor)

26. Date:

ETA Form 9061 (Rev. November 2016)

INSTRUCTIONS FOR COMPLETING THE INDIVIDUAL CHARACTERISTICS FORM (ICF), ETA 9061. This form is used together with IRS Form 8850 to help state workforce agencies (SWAs) determine eligibility for the Work Opportunity Tax Credit (WOTC) Program. The form may be completed, on behalf of the applicant, by: 1) the employer or employer representative, the SWA, a participating agency, or 2) the applicant directly (if a minor, the parent or guardian must sign the form) and signed (Box 25a.) by the individual completing the form. This form is required to be used, without modification, by all employers (or their representatives) seeking WOTCcertification.

Boxes 1 and 2. SWA. For agency use only.

Boxes3-5. Employer Information. Enter the name, address including ZIP code, telephone number, and employer Federal ID number (EIN) of the employer requesting the certification for the WOTC. Do not enter information pertaining to the employer’s representative, if any.

Boxes 6-11. Applicant Information. Enter the applicant’s name and social security number as they appear on the applicant’s social security card. In Box 8, indicate whether the applicant previously worked for the employer, and if Yes, enter the last date or approximate last date of employment. This information will help the “48-hour” reviewer to, early in the verification process, eliminate requests for former employees and to issue denials to these type of requests, or certifications in the case of “qualifying rehires” during valid “breaks in employment” (see pages III-12 and III-13, Nov. 2002, Third Ed., ETA Handbook 408) during the first year of employment.

Boxes 12-23. Applicant Characteristics. Read questions carefully, answer each question, and provide additional information where requested.

	The Protecting Americans from Tax Hikes Act of 2015 retroactively reauthorizedcurrent target groups for a 5-year period, January 1, 2015 through
	December31, 2019,andextendedtheEmpowermentZones designationsfora two-yearperiod,January1, 2015throughDecember31, 2016.TheAct
	introduced a new target group, Qualified Long-term Unemployment Recipient (LTUR), for new hires that begin to work for an employer on or after
	January 1, 2016 – December 31, 2019, see Box 23. For guidance see IRS Relief Period in TEGL No. TEGL 25-15 and IRS Notice 2016-22 and
	2016-40.
Box24	Sources to Document Eligibility. The applicant or employer is requested to provide documentary evidence to substantiate the YES answers in
	Boxes 12 - 23. List or describe the documentary evidencethat is attachedto the ICF or that will be providedto the SWA. Indicate in parentheses next
	to each document listed whetherit is attached(A) or forthcoming(F). Someexamples of acceptable documentationare providedbelow. A letterfrom
	the agency that administers a program may be furnished specifically addressing the question to which the applicant answered YES. For example, if
	an applicant answers YES to eitherquestionin Box14 andenters the nameof the primary recipient andthe city and statein which the benefits were
	received, the applicant could provide a letter from the appropriateSNAP (formerly FoodStamp) agencystating to whom SNAP benefits were paid, the
	months for whichthey were paid, and the names of the individuals included on the grant for eachmonth. SWAs use this boxto list the sources used
	to verifytarget groupeligibility,followedwiththeirinitials andthe datethedetermination wascompleted.

Description of Examples of Documentary Evidence and Collateral Contacts. Employers/Consultants: You may

check with your SWA to find out what other sources you can use to prove target group eligibility. (You are encouraged to provide copies of documentation or names of collateral contacts for each question for which you answered YES.)

QUESTION 12

Birth Certificate or Copy of Hospital Record

Driver’s License

School I.D. Card1

Work Permit1

Federal/State/Local Gov’t I.D.1

QUESTION 13

DD-214 or Discharge Papers

Reserve Unit Contacts

Letter of Separation or other agency documents issued only by the Department of Veterans Affairs (DVA) on DVA Letterhead certifying the Veteran has a service-connected disability and signed by the individual who verified this information.

QUESTIONS 14 & 16

TANF/SNAP (Food Stamp) Benefit History or Case Number Identifier

Signed statement from Authorized Individual with a specific description of the months benefits that were received

QUESTION 15

Vocational Rehabilitation Agency Contact

Veterans Administration for Disabled Veterans

Signed letter of separation or related document from authorized Individual on DVA letter head or agency stamp with specific description of months benefits were received.

For SWAs: To determine Ticket Holder (TH) eligibility, Fax page 1 of Form 8850 to MAXIMUS at: 703-683-1051 to verify

if applicant: 1) is a TH, and 2) has an Individual Work Plan from an Employment Network.

ETA Form 9061 (Rev. November 2016)

QUESTION 17

Parole Officer’s Name or Statement

Correction Institution Records

Court Records Extracts

QUESTION 18 & 19

To determine if a Designated Community Resident lives in a RRC, visit the site: www.usps.com. Click on Find Zip Code; Enter & Submit Address/Zip Code; Click on Mailing Industry Information; Download and Print the Information, then compare the county of the address to the list in the January 2012 Instructions to IRS8850.

To determine if the DCR or a Summer Youth lives in an Empowerment Zone, use the Empowerment Zones (EZ) Locator

Address Lookup tool available on the WOTC site: https://www.doleta.gov/business/incentives/opptax/resources.

QUESTION 20

SSI Record or Authorization

SSI Contact

Evidence of SSI Benefits

QUESTIONS 21, 22

Unemployment Insurance (UI) Claims Records

UI Wage Records

QUESTION 23

UI Wage Records

UI Claims Records

Self-Attestation Form, ETA Form 9175

QUESTION 24

Employers/Representatives: List All sources used and provided to the SWA to document target group eligibility. SWA Staff: List all documentation used to determine/verify eligibility in the target group requested by the employer/rep., to reach the final determination.

Notes:

1.Where a Federal/State/Local Gov’t., School I.D. Card, or Work Permit does not contain age or birth date, another valid document must be obtained to verify an individual’s age.

2.ESPL No. 05-98, dated 3/18/98, officially rescinded the authority to use Form I-9 as proof of age and residence. Therefore, the I-9 is no longer a valid piece of documentary evidence.

Box 25.(a) Signature. The person who completes the form signs the signature block.

Box 25(b) Signature Options. (a) Employer or Authorized Representative, (b) SWA staff, (c) Participating Agency staff, or (d) Applicant (If applicant is a minor, the parent or guardian must sign).

Box26. Date. Enterthemonth, dayandyear whentheform was completed.

Persons are not required to respond to this collection of information unless it displays a currently valid OMB Control Number. Respondent’s obligation to reply to these questions is required to obtain and retain benefits per law 104-188. Public reporting burden for this collection of information is estimated to average 20 minutes per response including the time for reading instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing 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 Control No. 1205-0371).

ETA Form 9061 (Rev. November 2016)

………………………………………………………………………………………………………………………………………………………………………………......

(Cut along dotted line and keep in your files)

TO: THE JOB APPLICANT OR EMPLOYEE,

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.

ETA Form 9061 (Rev. November 2016)

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Stage no. 1 in submitting form irs 8850 form

2. Just after filling out the last step, head on to the next part and fill out the essential details in these blanks - If YES enter your date of birth, Are you a Veteran of the US Armed, Yes No, If NO go to Box, If YES are you a member of a, Program SNAP benefits Food Stamps, before you were hired, Yes No, If YES enter name of primary, city and state where benefits were, OR are you a veteran entitled to, Yes No, If YES were you discharged or, OR were you unemployed for a, and consecutive during the year before.

Part # 2 for filling out form irs 8850 form

Always be very attentive while filling in If YES were you discharged or and Yes No, as this is the part in which many people make errors.

3. Your next stage is usually simple - fill out all the empty fields in before you were hired, Yes No, OR are you a member of a family, after August and the earliest, within years before you were hired, OR did your family stop being, because a Federal or state law, Yes No, YesNo, If NO are you a member of a family, the month period before you were, YesNo, If YES to any question enter name, the city and state where benefits, and Were you convicted of a felony or to finish the current step.

form irs 8850 form conclusion process clarified (step 3)

4. The following paragraph comes with the following fields to complete: Did you receive Supplemental, days before you were hired, Yes No, Are you a veteran unemployed for, consecutive during the year before, Yes No, Are you a veteran unemployed for, consecutive during the year before, Yes No, Are you an individual who is or, If YES what state did you receive, Enter state where UI compensation, Sources used to document, and I certify that this information is.

Filling out segment 4 of form irs 8850 form

5. Finally, this last section is precisely what you will need to wrap up prior to using the PDF. The fields under consideration are the following: a Signature See instructions in, Date, b Indicate with a mark who signed, and ETA Form Rev November.

form irs 8850 form conclusion process described (portion 5)

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