Form 9061 - Individual Characteristics Form Work Opportunity Tax Credit - U.s. Department Of Labor

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Individual Characteristics Form

U.S. Department of Labor

Work Opportunity Tax Credit

Employment & Training Administration

Individual Information

1. CONTROL NO.

OMB No. 1205-0371 Expires: 8/31/09

(For Agency Use Only)

(Instructions on the Back)

2. DATE RECEIVED

(For Agency Use Only)

3. EMPLOYER NAME/ADDRESS:

4. EMPLOYER FEDERAL ID NO.

5. EMPLOYMENT START DATE::

Starting Wage:

6. Have you worked for the above

employer before?

$_________________

per hour

Yes_____ No_____

POSITION:

If Yes, enter date and year: _____________

7. NAME OF INDIVIDUAL

(Last, First, Middle):

8. SOCIAL SECURITY NUMBER:

The above named individual is determined to have the following characteristics for WOTC target group certification:

9. Is your age between 18 but not age 40 or older?

10. Is a veteran and a member of a

11. Is a member of a family that received

family that received Food Stamps for a period of

TANF benefits for any 9 months in the last 18

at least 3 months in the last 15 months.

months.

Yes_____

No_____

Yes_____ No_____

Yes_______

No_______

If YES, also complete Box 17.

If YES, indicate your "Date of Birth" below:

Date of Birth: ______________________

12. Is a member of a family that received Food

13. In the past year, individual has been

14. Lives and plans to continue living in

Stamps for the last 6 months.

convicted of a felony or released

a federal Empowerment Zone,

from prison after a felony conviction.

Enterprise Round II or Renewal Community.

Yes_______ No________ , or

Yes______ No_______

for at least a 3-

month period within the Iast 5 months,

Yes ________ No ____

If YES, complete below:

BUT is no longer receiving them.

______________________________________

16. Received Supplemental Security Income

Date of Conviction _______________

(SSI) benefits for any month ending within the last

Yes_______ No______

60 days.

Date of Release ________________

Yes_________ No_______

If YES to either, also complete Box 17.

15. Is receiving or has received Rehabilitation

17. If individual is not a primary recipient of

Services through a State Rehabilitation Services’

benefits, please provide the following:

program or the Veterans' Administration.

_____________________________________

Yes_______ No________

Name of Primary Recipient

_____________________________________

City/State of Benefits

18. Is a “ticket holder” under the Ticket to Work Program

19. The “ticket holder” has an Individual Work Plan (IWP) from an Employment

Network (EN).

Yes _________ No _________

20. Is a member of a family that::

• Has received/is receiving TANF payments for at least the last 18 consecutive months;

Yes ____ No ____ or

• Has received/is receiving TANF payments for any 18 months starting after August 5, 1997;

and the earliest 18-month period beginning after August 5, 1997, and ended within the last 2 years; or Yes ______No

• Stopped being eligible for TANF payments within the last 2 years because Federal or state law

Yes _____ No ____

limited the maximum time those payments could be made, and having a hiring date not more than 2 years after the date of cessation of TANF benefits.

21. SOURCES USED TO DOCUMENT ELIGIBILITY:

Note: I certify that the Information is true and correct to the best of my knowledge. I understand that the information above may be subject to verification. The

signature of the party completing this form is required below. If applicant is a minor, the parent or guardian should sign this box.

22. SIGNATURE:

23. DATE:

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ETA Form 9061 (Rev. Dec. 2006)