Form ETA-9175 LONG-TERM UNEMPLOYMENT RECIPIENT SELF-ATTESTATION FORM W

U.S. Department of Labor

Employment and Training Administration

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

Work Opportunity Tax Credit
LONG-TERM UNEMPLOYMENT RECIPIENT (LTUR)
SELF-ATTESTATION FORM (SAF)
Instructions: The Self-Attestation Form (SAF) is to be completed, signed, and dated by the applicant / new
hire, only. Employers or their authorized representatives should submit the completed SAF along with IRS
Form 8850, Pre-Screening Notice and Certification Request for the Work Opportunity Tax Credit, or if filed
separately, with ETA Form 9061/ETA Form 9062, to the State Workforce Agency (SWA) for each certification
request submitted for the Long-Term Unemployment Recipient (LTUR) targeted group.

Applicant Self-Attestation: Under penalties of perjury, I declare that the information below is
true and correct to the best of my knowledge.
Applicant’s Full Name (Print: First, Middle Initial, Last): ____________________________________
Applicant’s Signature: _______________________________________ Date:_______
Applicant’s Social Security Number:

Date of Birth:(mm/dd/yyyy)

Employer’s Name: ___________________________________________________________
Employer’s Firm/Company Name: _______________________________________
Applicant Instructions : Please check “√” the statement below if it applies to you and fill in
the requested information below.
U

U

 I declare that I was/am in a period of unemployment that was/is at least 27 consecutive
weeks; and, for all or part of that unemployment period, I received unemployment
compensation under State or Federal law.
State(s) unemployment compensation was received:

.

I have been in a period of unemployment since (Enter unemployment start date: mm/dd/yyyy)___________
Privacy Act Notice:
Section 51 of the Internal Revenue Code of 1986, 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 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 to determine your employer's eligibility
for the federal work opportunity tax credit.
Public Burden Statement:
Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.
Respondents' obligation to complete this Form is required to obtain or retain benefits (P.L. 111-5). Public reporting burden is
estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of Information. Send comments
regarding this burden estimate 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).

ETA Form 9175 (Rev. May 2023)