Information Collection

Work Opportunity Tax Credit (WOTC)

IC 43791 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⚠️ Notice: This information collection may be referencing outdated material.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 9065 Work Opportunity Tax Credit (WOTC) Form and Instruction
ETA 9065 Agency Declaration of Verification Results ETA Form 9065_FINAL 11.10.16.doc Form and Instruction
ETA 9063 Employer Certification ETA Form 9063_FINAL 11.10.16.doc Form and Instruction
ETA 9061 Individual Characteristics Form ETA Form 9061 English_FINAL 11.10.16.doc Form and Instruction
ETA 9062 Conditional Certification ETA Form 9062_FINAL 11.10.16.doc Form and Instruction
ETA 9058 Certification Workload and Characteristics of Certified ETA Form 9058_FINAL 11.10.16.doc.docx Form and Instruction
ETA Form 9065 (track changes) 4.15.16.doc ETA 9065 IC Document
ETA Form 9063 (track changes) 4.15.16.doc ETA 9063 IC Document
ETA Form 9061 English_(track changes) 11.10.16.doc ETA 9061 IC Document
ETA Form 9062 (track changes) 4.15.16.doc ETA 9062 IC Document
ETA Form 9058 (track changes) 4.15.16.doc.docx ETA 9058 IC Document
Dept. Clearance TEGL WOTC 2015 Reauthorization 4.15.16.docx TEGL IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Work Opportunity Tax Credit (WOTC)	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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	ETA 9065	Agency Declaration of Verification Results	ETA Form 9065_FINAL 11.10.16.doc	Yes	Yes	Paper Only
Form and Instruction	ETA 9063	Employer Certification	ETA Form 9063_FINAL 11.10.16.doc	Yes	Yes	Fillable Fileable Signable
Form and Instruction	ETA 9061	Individual Characteristics Form	ETA Form 9061 English_FINAL 11.10.16.doc	Yes	Yes	Fillable Fileable Signable
Form and Instruction	ETA 9062	Conditional Certification	ETA Form 9062_FINAL 11.10.16.doc	Yes	Yes	Fillable Fileable Signable
Form and Instruction	ETA 9058	Certification Workload and Characteristics of Certified Individuals	ETA Form 9058_FINAL 11.10.16.doc.docx	Yes	Yes	Fillable Fileable Signable

Line of Business: Workforce Management

Subfunction: Training and Employment

Privacy Act System of Records
Title: DOL/ETA-15	FR Citation: 75 FR 6884

Number of Respondents: 52	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	3,830,058	0	3,830,058
Annual IC Time Burden (Hours)	1,312,610	2	1,312,608
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
ETA 9065	ETA Form 9065 (track changes) 4.15.16.doc	04/20/2016
ETA 9063	ETA Form 9063 (track changes) 4.15.16.doc	04/20/2016
ETA 9061	ETA Form 9061 English_(track changes) 11.10.16.doc	11/10/2016
ETA 9062	ETA Form 9062 (track changes) 4.15.16.doc	04/20/2016
ETA 9058	ETA Form 9058 (track changes) 4.15.16.doc.docx	04/20/2016
TEGL	Dept. Clearance TEGL WOTC 2015 Reauthorization 4.15.16.docx	05/08/2016

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