Eta Form 9062 – Fill Out and Use This PDF

Conditional Certification

U. S. Department of Labor

Work Opportunity Tax Credit

Employment & Training Administration

OMB No. 1205-0371

Expiration Date: 8/31/09

1. INITIATING AGENCY CODE (For Agency

2. CONTROL NO. (For Agency

3. TYPE OF CONDITIONAL CERT.

Use Only)

Use Only)

(“” One)

CONTROL NO.

(For Summer Youth ONLY)

CODE: ___________

_______________

a.  Original b.  Revalidation

______ Participating Agency______

SWA/DLA

____ Participating Agency

____ SWA/DLA

4. FOR EX-FELON TARGET GROUP ONLY.

a. Conviction/Release Date:

5. DATE COMPLETED (Mo., Day,

Yr.)

___________________

b. Corrections Institution ID

_________________

No:___________

6. State Workforce Agency’s Name and Address

7. SIGNATURE (Authorized Official)

8. TELEPHONE NO.

PART I. INTRODUCTION

9. NAME OF INDIVIDUAL (Last, First, Middle)

10. SOCIAL SECURITY NO.

11. ADDRESS (Number, Street, City, State, Zip Code) 12. TARGET GROUP CODE (“” One)

Enter Code if not a TH or SY:_______________

13. APPLICANT’ SIGNATURE:

NOTE TO EMPLOYER:

14. The above named individual may be eligible for

In the event you hire this person, you should request the certification

certification under the Work Opportunity Tax Credit. If

necessary for you to claim a Work Opportunity Tax Credit. Simply,

not employed before the date in the box below (Mo.,

complete and sign the Employer Declaration below, mail to the SWA or

Day, Yr.), this eligibility determination is subject to

Designated Local Agency together with the PSN-IRS Form 8850, not

review.

later than the 28th day after the applicant starts work. The WOTC

Employer Certification Form will be sent to you, if all statutory requirements

have been met.

15. NAME OF FIRM:

16. POSITON/JOB TITLE:

17. EMPLOYMENT-START

18. STARTING

DATE: (Mo., Day, Yr.)

WAGE:

$ _________ per

hour

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ETA Form 9062 (Rev. Dec. 2006)

Box 1:

Initiating Agency Code. If the CC was issued by a participating agency (PA), enter its code. SWAs/DLAs 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/DLA, enter the SWA/DLA code, if available. Indicate with a check mark “” if

initiating agency is aParticipatingAgency or SWA/DLA.

Box 2:

Control Number. Usually the PA determines thecontrol number (CN). However, SWAs/DLAs may, for internal control

purposes, develop their own CNsystem. It may be aSocial Security No., case no., or some other appropriate designation, which

permits easy filing, certification and retrieval of forms. Enter corresponding CN and indicate with a check mark “” whether the

source is aPA or a SWA/DLA.

Box 3:

Type of Conditional Certification. This system distinguishes between “Original,” if the individual is being processed for thefirst

time, or “Revalidation,” if the eligibility process was performed within the previous 12-month period, (e.g. , 45 days for theSummer

Youth target group only). Otherwise, the Conditional Certification is counted as “Original.” Indicate with a check mark “” whether

eligibility determination is “Original” or “Revalidation.”

Box 4:

For Ex-Felon Target Group Only. For items a - c, enter the corresponding information. This information will help youin

verifyingtarget group eligibility.

Box 5:

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

Box 6:

SWA/DLAName and Address. (If known, enter orstamp the name and address, including zipcode, of theSWA/DLA

responsible for Certifications requests for the employer indicated in Box 16. Leave blank if SWA/DLA’s name and address is

unknown.

Box 7:

Signature. Entersignature of the authorized conditionally-certifying official.

Box 8:

Telephone No. Enter corresponding SWA/DLA or participating agency area code, telephone number and extension, if available.

PART I.

INTRODUCTION:

Box 9:

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

Box 10:

Social SecurityNumber. Enterthe individual’s/applicant social security number.

Box 11:

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

address, enter individual’s/applicant’s telephone number, including area code.

Box 12:

Target Group Code. Enter acheck mark “” to indicate if “SummerYouth, “Ticket Holder (TH)” with an IWP from an

Employment Network (EN) or Other.” If different from SummerYouth or Ticket Holder, enter codefor specificWOTC target

group based on client’s information and documentation provided.

Box 13:

Signature. Get Individual’s/applicant’s signature. If aminor, parent or guardianmust sign here.

Box 14:

CC ValidityPeriod. (This box is to becompleted by the SWA/DLA or PA). Enter the month/day/year when the CC expires

(e.g. 45 days for Summer Youth)

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ETA Form 9062 (Rev. Dec. 2006)

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ETA 9062 (Rev. Dec. 2006)