IndividualCharacteristicsForm(ICF) WorkOpportunityTaxCredit

1.ControlNo.(ForAgencyuseonly)

U.S.DepartmentofLabor
EmploymentandTrainingAdministration OMBNo.12050371 ExpirationDate:November30,2011 2.DateReceived(ForAgencyUseonly)

APPLICANTINFORMATION
(Seeinstructionsonreverse)

3.EmployerName

EMPLOYERINFORMATION 4.EmployerAddressandTelephone 5.EmployerFederalIDNumber(EIN)

APPLICANTINFORMATION 6.ApplicantName(Last,First,MI) 7.SocialSecurityNumber. 8.Haveyouworkedforthisemployer before? Yes____No____ IfYES,enterlastdateof employment:____________ APPLICANTCHARACTERISTICSFORWOTCTARGETGROUPCERTIFICATION 9.EmploymentStartDate 10.StartingWage 11.Position

12. Areyouatleastage16,butunderage40? IfYES,enteryourdateofbirth _____________________ 13. AreyouaVeteranoftheU.S.ArmedForces? IfNO,gotoBox14. IfYES,areyouamemberofafamilythatreceivedFoodStampsforatleast 3monthsduringthe15monthsbeforeyouwerehired? IfYES,enternameofprimaryrecipient_______________________and cityandstatewherebenefitswerereceived_________________. OR,areyouaveteranentitledtocompensationforaserviceconnecteddisability? IfYES,wereyoudischargedorreleasedfromactivedutywithinayearbeforeyou werehired? OR,wereyouunemployedforacombinedperiodofatleast6monthsduringthe yearbeforeyouwerehired? 14. AreyouamemberofafamilythatreceivedFoodStampsforthe6monthsbeforeyou werehired? OR,receivedFoodStampsforatleasta3monthperiodwithinthelast5months Butyouarenolongerreceivingthem? IfYEStoeitherquestion,enternameofprimaryrecipient_____________________ andcityandstatewherebenefitswerereceived_____________________.
1

Yes___No___ Yes___No___

Yes___No___

Yes___No___ Yes___No___ Yes___No___ Yes___No___ Yes___No___

ETAForm9061November2008

15.WereyoureferredtoanemployerbyaVocationalRehabilitationAgencyapprovedby aState? Yes___No___ OR,byanEmploymentNetworkundertheTickettoWorkProgram? Yes___No___ OR,bytheDepartmentofVeteransAffairs? Yes___No___ 16. AreyouamemberofafamilythatreceivedTANF assistanceforatleastthelast18monthsbeforeyouwere hired? Yes___No___ OR,areyouamemberofafamilythatreceivedTANFbenefits forany18monthsbeginningafter August5,1997,andtheearliest18monthperiodbeginningafterAugust5,1997,endedwithin2yearsbefore youwerehired? Yes___No___ OR,didyourfamilystopbeingeligibleforTANFassistancewithin2yearsbeforeyouwerehiredbecause aFederalorstatelawlimitedthemaximumtimethosepaymentscouldbemade? Yes___No___ IfNO,areyouamemberofafamilythatreceivedTANFassistanceforany9monthsduring the18monthperiodbeforeyouwerehired? Yes___No___ IfYES,toanyquestion,enternameofprimaryrecipient________________________and thecityandstatewherebenefitswerereceived_________________________. 17. Wereyouconvictedofafelonyorreleasedfromprisonafterafelonyconvictionduring theyearbeforeyouwerehired? IfYES,enterdateofconviction________________anddateofrelease_________________. WasthisaFederal____oraStateconviction_____?(Checkone) 18.DoyouliveinanEmpowermentZoneorRenewalCommunity? OR,inaRuralRenewalCounty(RRC)? IfYES,enternameoftheRRC:_____________________________ Yes___No___

Yes___No___ Yes___No___

19. DidyoureceiveSupplementalSecurityIncome(SSI)benefitsforanymonthendingwithin 60daysbeforeyouwerehired? Yes___No___ 20. Sourcesusedtodocumenteligibility:(Employers/Consultants:Listalldocumentationprovidedorforthcoming. SWAs:

Listalldocumentationusedindeterminingtargetgroupeligibilityandenteryourinitialsanddatewhendeterminationwasmade.)

Icertifythatthisinformationistrueandcorrecttothebestofmyknowledge. Iunderstandthatthe informationabovemaybesubjecttoverification. 21(a).Signature:(SeeinstructionsforBox21forwhosignsthissignature

block) 21.(b)Indicatewithawhosignedtheform: Employer, Consultant, SWA, ParticipatingAgency,Applicant,or Parent/Guardian(ifapplicantisaminor)

22.Date:

ETAForm9061November2008

INSTRUCTIONSFORCOMPLETINGTHEINDIVIDUAL CHARACTERISTICSFORM(ICF), ETA9061. ThisformisusedtogetherwithIRSForm8850to helpstateworkforceagencies(SWAs) determineeligibilityfortheWorkOpportunityTaxCredit (WOTC)Program. Theformmaybecompleted,onbehalfof theapplicant, by: 1) theemployeroremployerrepresentative,theSWA, a participating agency,or by2) the applicantdirectly (ifaminor,theparentorguardian mustsign the form)and signedbythe individual completingthe form.Thisformisrequiredtobeused,withoutmodification, byallemployers (ortheir representatives)seekingWOTC certification. Boxes1 and2. SWA. Foragencyuseonly. Boxes35. EmployerInformation. Enterthename,addressincludingZIPcode,telephonenumber,andemployerFederalIDnumber(EIN)ofthe employerrequestingthecertificationfortheWOTC. Donotenterinformationpertainingtotheemployersrepresentative,ifany. ApplicantInformation. Entertheapplicantsnameandsocialsecuritynumberastheyappearontheapplicantssocialsecurity card.InBox8,indicatewhethertheapplicantpreviouslyworkedfortheemployer,andifYes,enterthelastdateorapproximatelast dateofemployment. Thisinformationwillhelpthe48hourreviewerto,earlyintheverificationprocess,eliminaterequestsfor formeremployeesandtoissuedenialstothesetypeofrequests,orcertificationsinthecaseofqualifyingrehiresduringvalid breaksinemployment(seepagesIII12andIII13,Nov.2002,ThirdEd.,ETAHandbook408)duringthefirstyearofemployment.

Boxes611.

Boxes1219. ApplicantCharacteristics. Readeachquestioncarefully,answereachquestion,andprovideadditionalinformationwhere requested. Box20. Sourcesto Document Eligibility. Theapplicantoremployer isrequestedto provide documentaryevidencetosubstantiatethe YESanswers on page 1. List or describethedocumentaryevidencethat is attachedtotheICForthatwillbeprovided totheSWA.Indicateinparenthesesnextto eachdocumentlistedwhetheritis attached (A) orforthcoming (F).Someexamples ofacceptabledocumentaryevidence areprovidedbelow. A letterfromtheagencythatadministersa relevantprogram maybefurnishedspecificallyaddressingthequestiontowhichtheapplicantanswered YES.Forexample,ifanapplicantanswersYEStoeitherquestioninBox14andentersthenameoftheprimaryrecipientandthecityandstatein whichthebenefitswerereceived,theapplicantcould provide aletterfromtheappropriate Food Stampagencystatingtowhom Food Stampbenefits werepaid,themonthsforwhichtheywerepaid,and thenamesoftheindividualsincludedonthegrantforeachmonth. SWAswillusethisboxto documentthe sourcesused when verifyingtargetgroupeligibility,followedbytheirinitialsand the date thedeterminationwas completed.

ExamplesofDocumentaryEvidenceandCollateralContacts. Employers/Consultants: Youmaycheckwith yourSWAtofindoutwhatothersourcesyoucanusetoprovetargetgroupeligibility.(Youareencouragedtoprovide copiesofdocumentationornamesofcollateralcontactsforeachquestionforwhichyouansweredYES.)

QUESTION12 BirthCertificate DriversLicense SchoolI.D.Card* WorkPermit* Federal/State/LocalGovtI.D.* CopyofHospitalRecordofBirth QUESTION13 SSIRecordorAuthorization DD214 ReserveUnitContacts DischargePapers QUESTIONS14&16 TANF/FoodStampBenefit History SignedStatementfromAuthorizedIndividualwithSpecific DescriptionoftheMonthsBenefitsWereReceived CaseNumberIdentifier QUESTION15 VocationalRehabilitationAgencyContact VeteransAdministration SignedStatementfromAuthorizedIndividual WithSpecificDescriptionofMonthsBenefitsReceived ForSWAs:TodetermineTicketHolder(TH)eligibility, Faxpage1ofForm8850toMAXIMUSto7036831051to verifyifapplicant: 1)isaTH,and2)hasanIndividualWorkPlanfromand EmploymentNetwork. QUESTION17 ParoleOfficersNameor Statement CorrectionInstitutionRecords CourtRecordsExtracts QUESTION18 DriversLicense WorkPermit UtilityBills W4 LeasePapers LibraryCard** VoterRegistrationCard FoodStampAwardLetter SelectiveServiceRegistrationCard TodetermineifaDesignatedCommunityResidentlivesin aRRC,visitthesite:www.usps.com. ClickonFindZip CodeEnter&SubmitAddress/ZipCodeClickon MailingIndustryInformationDownloadandPrintthe Information, thencomparethecountyoftheaddressto thelistintheJune2007InstructionstoIRS8850. QUESTION19 SSIRecordorAuthorization SSIContact EvidenceofSSIBenefits
Notes.1. WhereaFederal/State/LocalGovt.,SchoolI.D.Card,orWorkPermit doesnotcontainageorbirthdate,anothervaliddocumentmustbeobtainedto verify anindividualsage. 2. WhereaLibrary Carddoesnotcontaintheholdersaddressanotherdocument, issuedinthejurisdictionwheretheEZ/RCorRRCountyislocated,mustbe obtainedshowingtheholdersaddress. 3.ESPLNo.0598,dated3/18/98,officiallyrescindedtheauthoritytouseFormI9 asproofofageandresidence. Therefore,theI9isnolongeravalid pieceofdocumentaryevidence. ETAForm9061November2008

Box 21. Signature. Thepersonwhocompletestheformsignsthesignatureblock.Options: (a)EmployerorAuthorizedRepresentative, (b)SWAstaff, (c)ParticipatingAgencystaff,or (d)Applicant(Ifapplicantisaminor,theparentorguardianmustsign). Box 22: Date. Enterthemonth,dayandyearwhentheformwascompleted.

Persons are notrequired torespondtothiscollectionofinformationunlessitdisplaysacurrentlyvalidOMBControlNumber.Respondentsobligationtoreplytothese questions isrequiredtoobtain andretainbenefitsperlaw104188.Publicreportingburdenforthiscollectionofinformationisestimatedtoaverage20minutesper responseincludingthetimeforreadinginstructions,searchingexistingdatasources,gatheringandmaintainingthedataneeded,andcompletingandreviewingthe information.Sendcommentsregardingthisburdenestimateoranyotheraspect ofthiscollectionofinformation,includingsuggestionsforreducingburdentotheU.S. DepartmentofLabor,EmploymentandTrainingAdministration,DivisionofAdult Services,RoomS4209,Washington,D.C. 20210(PaperworkReductionProject Control No.12050371).

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TO: THEJOBAPPLICANTOREMPLOYEE, THEINFORMATIONANDTHESUPPORTINGDOCUMENTATIONYOUHAVEPROVIDEDIN COMPLETINGTHISFORM ORINSOMECASESOTHERINFORMATIONTHATCOULD VERIFYTHERESPONSESYOU HAVEGIVENTOTHEITEMS/QUESTIONSINTHISFORM WILLBEDISCLOSEDBYYOUREMPLOYERTO THESTATEWORKFORCEAGENCY(SWA). ENTER THE SWAs NAMEBELOW: ________________________________________________________________________________________________

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INORDERTOQUALIFYFORAFEDERALEMPLOYERTAXCREDIT,PROVISION OFTHIS INFORMATIONIS VOLUNTARY.HOWEVER,THEINFORMATIONISREQUIREDFORYOUR EMPLOYERTORECEIVETHEFEDERALTAXCREDIT.IFTHEINFORMATIONYOU PROVIDEISABOUTAMEMBEROFYOURFAMILY,YOUSHOULDPROVIDEHIM/HERA COPY OFTHISNOTICE.

ETAForm9061November2008