Information Collection

Qualified Long-term Unemployment Recipient (LTUR)

IC 221431 under ICR 201611-1205-003 · OMB 1205-0371.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1205-0371 can be found here:

Documents and Forms

Document Name Document Type
Form ETA 9175 Qualified Long-term Unemployment Recipient (LTUR) Form
ETA 9175 LONG-TERM UNEMPLOYMENT RECIPIENT SELF-ATTESTATION FORM WOTC SAF for Long-Term Unemployment Recipient ETA Form 9175_FINAL 11.10.16.doc Form
WOTC SAF for Long-Term Unemployment Recipient ETA Form 9175 (track changes) 11.10.16.doc Form ETA 9175 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Qualified Long-term Unemployment Recipient (LTUR)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	ETA 9175	LONG-TERM UNEMPLOYMENT RECIPIENT SELF-ATTESTATION FORM	WOTC SAF for Long-Term Unemployment Recipient ETA Form 9175_FINAL 11.10.16.doc		Yes	Yes	Fillable Fileable Signable

Line of Business: Workforce Management

Subfunction: Training and Employment

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 95,741	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Farms, Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	95,741	95,741
Annual IC Time Burden (Hours)	16,276	16,276
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Form ETA 9175	WOTC SAF for Long-Term Unemployment Recipient ETA Form 9175 (track changes) 11.10.16.doc	11/10/2016

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.