ETA-9063 Employer 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
Employer Certification
(OPTIONAL FORMAT)

STATE WORKFORCE AGENCY (AGENCY) INFORMATION
2. CONTROL NO.
3. DATE COMPLETED: (mm/dd/yyyy)
(For Agency Use Only)

1. NAME, ADDRESS & TELEPHONE NO. OF
CERTIFYING AGENCY:

4. INITIATING AGENCY CODE: (For Agency Use Only)

PART A. EMPLOYER INFORMATION
5. NAME, ADDRESS & TELEPHONE NO. OF
EMPLOYER’S FIRM/COMPANY:

6. EMPLOYER
IDENTIFCATION NO. (EIN):

7. EMPLOYER REPRESENTATIVE’S
NAME, TITLE & ADDRESS (if applicable):

PART B. EMPLOYEE INFORMATION
8. APPLICANT’S SOCIAL SECURITY NO.:

9. EMPLOYMENT START DATE: (MM/DD/YYYY)

10. NAME AND ADDRESS OF EMPLOYEE:

12. VETERAN TARGETED GROUP CODES: (select those that apply)







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

11. TARGETED GROUP CODE AND NAME:
(Enter Non-Veteran targeted groups, only):
________________________________________
Note to Employers: Additional information on filing WOTC certification requests with State Workforce Agencies (SWA) .
Employers are also encouraged to visit the IRS.gov website to obtain copies of the newly revised IRS Form 8850.
27TU

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Before employers may claim the work opportunity credit, the employee (new hire) must perform at least 120 hours of
service for the employer to meet the Minimum Employment or Retention Period. For additional information, see the
FAQ page for Work Opportunity tax Credit.
PART C. AGENCY CERTIFICATION

I, HEREBY, CERTIFY that the individual named in Part B meets the eligibility criteria of Section 51(d) of the
Internal Revenue Code of 1986, as amended.
13. NAME OF CERTIFYING OFFICER:
(Print or Type)

14. SIGNATURE: (CERTIFYING OFFICER)

15. DATE ISSUED:
(mm/dd/yyyy)

NOTE: Falsification of data to obtain this Certification is a FEDERAL CRIME in violation of 18 USC 1001.
Falsification of work or concealment of information is PUNISHABLE by a fine or imprisonment.

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ETA Form 9063 (Rev. Feb 2023)

INSTRUCTIONS FOR COMPLETING AND ISSUING THE EMPLOYER CERTIFICATION - ETA FORM 9063
Documentary evidence and/or collateral contacts is required to determine applicant targeted group eligibility and issue a WOTC Employer
Certification. Issuance of an Employer Certification validates the new hire/employee’s targeted group eligibility under Section 51 of the
Internal Revenue Code of 1986, as amended, and it confirms the employer is entitled to claim the work opportunity credit against the
qualified wages paid to the new hire. See the Instructions to IRS Form 5884 and IRS Form 5884-C for more information.
Note: It is not the responsibility of the SWAs to verify that an employee certified to be a member of a targeted group has
worked the required number of hours for the employer, under section 51(i)(3) of the Code. SWAs are only responsible for
verifying and certifying an applicant’s eligibility as a member of a targeted group. The responsibility for verifying the required
number of hours worked rests with the IRS.
The Employer Certification should be completed in entirety by an authorized official of the state workforce
agency or certifying agency. See instructions below for each of the Boxes to be completed by the SWA:

Box 1.

Name and Address. Identify the SWA and include the appropriate address and zip code.

Box 2.

Control Number. Enter the control number developed by the SWA for its own use.

Box 3.

Date Completed. Enter the month, day and year when the form was completed.

Box 4.

Initiating Agency Code. Enter agency code developed by SWA for its own use.

Box 5.

Name and Address of Firm. Enter employer's company name and address, including zip code.

Box 6.

Employer Identification Number (EIN). Enter employer’s federal taxpayer identification number.

Box 7.

Representative's Name, Title and Address. Enter the name, title and office location of the
individual authorized by the employer to act on the employer’s behalf.

Box 8.

Social Security No. Enter the employee's full social security number.

Box 9.

Employment Start Date. Enter the month, day and year when the employee began to work for the
employing firm.

Box 10.

Name and Address of Employee. Enter the employee's full name (i.e., last name, first name and
middle initial) and mailing address, including zip code, and telephone number, if available.

Box 11.

Targeted Group. Enter SWA Code and targeted group name for the certified group.

Box 12.

Veteran Targeted Group. Indicate which veteran subgroup the employee (new hire) is being
certified under.

Box 13.

Certifying Official. Enter full name and title of authorized certifying official.

Box 14.

Signature. Enter authorized, certifying official's signature.

Box 15.

Date. Enter date (mm/dd/yyyy) when the Employer Certification is issued by the certifying agency.

Persons are not required to respond to this collection of information unless it displays a currently valid
OMB Control Number. Respondent's obligation to reply to these requirements is mandatory under 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 instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the information. Send comments regarding
the burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to the U.S. Department of Labor, Division of National Programs, Tools, and
Technical Assistance, Room C-4510, Washington, D.C. 20210 or email: ETA-PRA@dol.gov
(Paperwork Reduction Project 1205-0371).

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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 process. The information applicants (new hires) have provided
associated WOTC processing forms will be disclosed to the State Workforce Agency. Provision of this
information is voluntary, however; the information is required for employers to receive the federal work
opportunity 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 9063 (Rev. May 2023)