Form ETA-9062 Conditional Certification Work Opportunity Tax Credit

OMB Control No. 1205-0371
Expiration Date: May 31, 2026

U.S. Department of Labor
Employment and Training Administration

Work Opportunity Tax Credit
Conditional Certification Form (CC)
INSTRUCTIONS FORM EMPLOYERS:

 This form must be accompanied by IRS Form 8850. If you do not have IRS Form 8850, download it from https://www.irs.gov .
 Be sure to complete Part II of this Form and IRS 8850. Sign and date both Forms BEFORE sending them to the State Workforce Agency (SWA) within 28
days after the new hire’s employment start date. See reverse side for additional Form instructions.
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PARTICIPATING AGENCY / STATE WORKFORCE AGENCY (SWA) INFORMATION:
1. INITIATING AGENCY CODE: ___________
(For Agency Use Only)

2. CONTROL NO. (For Agency Use Only):

3. DATE COMPLETED:
(mm/dd/yyyy)

__________________________________
Check “” One: ____ SWA

__________________________

____ Participating Agency
4. SWA’S NAME / MAILING ADDRESS:

5. TELEPHONE NUMBER:

6. AUTHORIZED SIGNATURE:
(Agency / SWA Official)

_______________________
PART I. APPLICANT’S INFORMATION AND CONDITIONAL CERTIFICATION (CC):
9. APPLICANT’s SOCIAL SECURITY
NUMBER

7. NAME OF APPLICANT
(Last, First, Middle)

8. APPLICANT’S ADDRESS (Include Street, City,
State, Zip Code) AND TELEPHONE NUMBER:

10. ENTER TARGETED GROUP CODE NO. /
TARGETED GROUP NAME
(for the applicant seeking certification):

11. QUALIFIED VETERAN TARGETED GROUP CODES (Please Check “” One):
 2Ba. Veteran receiving SNAP benefits
 2Bb. Disabled Veteran
 2Bc. Disabled Veteran unemployed for 6 months
 2Bd. Veteran unemployed for 4 weeks but less than 6 months
 2Be. Veteran unemployed for 6 months

_______________________

_________

12. FOR EX-FELON TARGETED GROUP:
a. State or Federal Conviction:
b. Conviction Date: _________________
c. Release Date: ___________________
d. Ex-felon’s Corrections ID No. :
____________________________________

..

13. FOR SUMMER YOUTH EMPLOYEE TARGETED GROUP:

The job applicant may be eligible for WOTC certification. If the individual is not employed
before the date in the box above (enter MM/DD/YYYY), this eligibility determination is
subject to review.

14. APPLICANT’S SIGNATURE:

DATE:

Note to Employers: In the event that you hire this individual, you should request the necessary Certification from the SWA for you to claim the Work Opportunity Credit.
Complete, sign, and submit this Form together with IRS Form 8850 to the SWA in which your business is located. IRS Form 8850 must be submitted to the SWA within 28
calendar days of the new hire’s start date to meet timely filing requirement. If all statutory targeted group eligibility and timely filing requirements have been met for your
certification request, the SWA will issue you an Employer Certification.

PART II. EMPLOYER DECLARATION: I hereby declare that the above-named applicant is or will be employed by the date provided below in
box 16. Falsification of data on this Form is a FEDERAL CRIME in violation of 18 USC 1001. Falsification of work or concealment of
information is PUNISHABLE by a fine or imprisonment.
15. NAME OF FIRM/COMPANY AND FIRM’S MAILING ADDRESS:

16. APPLICANT’S EMPLOYMENT
START DATE (MM/DD/YY):
.

17. POSITON / JOB TITLE:
18. STARTING WAGE:
$ ___________ per hr

ATTN SWA: Please send an Employer Certification for this employee. This pre-certification is for the purpose of requesting the Work Opportunity Credit under Sec. 51 and 52
of the Internal Revenue Code. Employers are advised that such credit will cease immediately upon notification of any subsequent invalidation/revocation.

19. EMPLOYER’S NAME:

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20. EMPLOYER’S SIGNATURE:

21. DATE: (MM/DD/YY)

ETA Form 9062 (Rev. May 2023)

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 - 6 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 .
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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 alphanumeric 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:
wage.

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

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ETA Form 9062 (Rev. May 2023)

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 or
email: ETA-PRA@dol.gov (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.

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ETA Form 9062 (Rev. May 2023)