Application 9061

Individual Characteristics Form (ICF) - Work Opportunity Tax Credit

Job Applicant Information

EMPLOYER INFORMATION

3. Employer Name

4. Employer Address

5. Employer Federal ID Number (EIN)

APPLICANT INFORMATION

6. Applicant Name

7. Social Security Number

8. Have you worked for this employer before?*
Yes No

APPLICANT CHARACTERISTICS FOR WOTC TARGET GROUP CERTIFIATION

9. Employment Start Date

10. Starting Wage ($$/hour)*

11. Position*

Directions: Read the following statements carefully and check any of following statements that apply to the job applicant. Provide additional information where requested and as needed for targeted group eligibility determination.

12. Qualified IV-A Recipient

Check here if the job applicant is a Qualified IV-A Recipient

If the job applicant is a member of a family receiving Temporary Assistance for Needy Families (TANF)

Enter the name of the primary benefits recipient

and where benefits were received:

City

State(s)

13. Qualified Veteran

Check here if the job applicant is a veteran of the U.S. Armed Forces

If the job applicant (veteran) is a member of a family receiving Supplemental Nutrition Assistance Program (SNAP) benefits

Enter the name of the primary benefits recipient:

and where benefits were received:

City

State(s)

Note: Additional information may be requested to determine the job applicant's qualified veteran eligibility, such as proof of being entitled to compensation for a service-connected disability or having aggregate periods of unemployment.

14. Qualified Ex-Felon

Check here if the job applicant is an Ex-Felon

Enter date of felony conviction (mm/dd/yyyy):

and release date:

Federal conviction:

State conviction:

List applicable state:

Check here if the job applicant is in a Work Release Program:

15. Designated Community Resident (DCR)

Check if the job applicant is at least age 18 but not age 40 on the hiring date, and resides in

a Rural Renewal County (RRC)

an Empowerment Zone (EZ).

Enter job applicant's birthday (mm/dd/yyyy):

16. Vocational Rehabilitation Referral

Check here if the job applicant is a Vocational Rehabilitation (VR) Referral

17. Qualified Summer Youth Employee

Check here if the job applicant is a Qualified Summer Youth Employee

Enter the job applicant's birthday (mm/dd/yyyy):

18. Qualified Supplemental Nutrition Assistance Program (SNAP) Recipient

Check here if the job applicant is a Qualified SNAP (Food Stamps) Recipient

Enter job applicant's birthday (mm/dd/yyyy)

Enter the name of the primary benefits recipient:

and where benefits were received:

City

State(s)

19. Qualified Supplemental Security Income (SSI) Recipient

Check here if the job applicant received or is receiving Supplemental Security Income (SSI)

20. Long-Term Family Assistance Recipient

Check here if the job applicant is a Long-term Family Assistance (long-term TANF) recipient

Enter name of the primary benefits recipient:

and where benefits were received:

City

State(s)

21. Qualified Long-Term Unemployment Recipient

Check here if the job applicant is a qualified long-term unemployment recipient (LTUR)

Enter where UI claim records / UI wage records were filed:

City

State(s)

Indicate who signed the form

Employer

Employer's Preparer

SWA / Participating Agency

Job Applicant

Parent/Guardian (if job applicant is a minor)

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

* Check in lieu of your Signature

Name of Person Signing*

WOTC requirement for Food Stamp target group eligibility is that the new hire be between the ages of 18-39.

WOTC requirement for the RRC/DCR target group eligibility is that the new hire be between the ages of 18-39.

No target group was selected on your application. Please review your entries.