ETA-9062 Tracked Changes

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Conditional Certification Form (CC)
Work Opportunity Tax Credit

                                                                                                                                             
CONDITIONAL CERTIFICATION (CC) ETA FORM 9062.   When a state workforce agency (SWA) or participating agency (PA) 
determines that a job-ready applicant is tentatively ELIGIBLE as a member of a targeted group under WOTC, the agency shall 
use this required CC Form, without modification, to show that eligibility pre-determination was made for the applicant.  
Note: The CC serves as an official record of the pre-certification, alerts prospective employers to the availability of the tax credit if the 
applicant is hired, and provides a means for employers to request a WOTC Employer Certification for the applicant.

INSTRUCTIONS FOR COMPLETING ETA FORM 9062, CONDITIONAL CERTIFICATION:  

BOXES 1 - 8 ARE FOR PARTICIPATING AGENCY / STATE WORKFORCE AGENCY (SWA) USE ONLY.

Box  1:	Initiating Agency Code.  If the CC was issued by a Participating Agency (PA), enter its code.  SWAs 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, enter the SWA’s code.  Indicate with a check mark “” if initiating agency is a PA or SWA.

Box  2: 	Control Number.   Usually, the PA determines the control number (CN).  However; SWAs may, for internal control purposes, develop their own CN system.   It may be a case number or some other appropriate designation (e.g., alpha-numeric code), which permits easy filing, certification and retrieval of forms.  Enter corresponding CN and indicate with a check mark “” whether the source is a PA or a SWA.

Box  3:	Date Completed.   Enter the month, day, year in which the eligibility determination was completed 

Box  4:	SWA’s Name and Address.  If known, enter or stamp the name and address, including zip code, of the State Workforce Agency (SWA) responsible for processing certification requests for the employer indicated in Box 15.   Leave blank if SWA’s name and address is unknown.

Box  5:	Telephone No.  Enter corresponding SWA or PA area code, telephone number and extension, if applicable. 

Box  6:	Signature.  Enter signature of the authorized conditionally-certifying official.

PART I.  APPLICANT’S INFORMATION AND CONDITIONAL CERTIFICATION (CC):

Box  7:	Name of Applicant.  Enter the individual’s/job applicant’s full name (i.e., last name, first name and middle initial).

Box  8:  	Address/Telephone No.  Enter the individual’s/applicant’s home address, including apartment number and zip code.  
After address, enter individual’s telephone number, including area code.

Box 9:	Social Security Number.   Enter the individual’s/applicant’s Social Security Number, as it appears on their Social Security Card.

Box 10:	Targeted Group Code.  Enter the code or name of the pre-certified targeted group.  
For targeted group names and eligibility definitions, visit https://www.irs.gov/businesses/small-businesses-self-employed/work-opportunity-tax-credit#targeted. 

Box 11:	Veteran Targeted Group Codes.  The original targeted group designation for a Qualified Veteran is “B.”  To facilitate the identification of the different subcategories of qualified veterans created by the VOW to Hire Heroes Act of 2011 (P.L. 112-56), and to ensure a simple, uniform and consistent certification system which can be used by the SWAs nationwide, ETA uses the same alpha-numeric designations for the qualified veteran categories used in ETA Form 9058, WOTC Report 1.  Each veteran category is preceded by “B” and followed by the alpha-numeric code used in ETA Form 9058.   Enter a check mark “” in front of the qualified veteran subgroup for which the applicant is pre-certified.  

Box  12:	For Ex-Felon Targeted Group Only.   For items a - d, enter the corresponding information.  This information will help the SWA or PA in verifying targeted group eligibility.  

Box  13: 	CC Validity Period (For Summer Youth Employee Targeted Group Only).  This box is to be completed by the SWA or PA).  Enter the month/day/year when the Conditional Certification expires. This box does not apply to qualified veterans, nor any other targeted group under Section 51 of the Internal Revenue Code except for Summer Youth Employee applicants.

Box 14:	Signature.   Get the (job) applicant’s signature.  If the applicant is a minor, the parent or guardian must sign.  Enter date.  

PART II.  EMPLOYER DECLARATION & EMPLOYER INFORMATION:

Box 15:	     Name of Company/Firm.   Enter full name of the employing firm (the firm where the employee receives wages from).

Box 16:	Employment-Start Date.   Enter the date the employee began or will begin work for the employing firm.

Box 17:	Position/Job Title.    Enter the position or job title the employee will hold/was offered employment under.

Box 18: 	Starting Wage.  Enter the wage or salary which the employee will be paid/was hired under.  If not known, enter an estimated hourly wage.

Box 19:	Employer’s Name.  Enter your name as the hiring employer.

Box  20:	Employer’s Signature.  Affix your electronic or ink signature here.

Box  21:	Date.  Enter month, day and year when you signed this form.


Persons are not required to respond to this collection of information unless it displays a currently valid OMB Control Number.   Respondents’ obligation to reply to these questions is required for obtaining the tax credit per P.L. 104-188.  Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reading instruction, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.   Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing the 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 1205-0371)


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 by 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.