Form ETA-9065 Audit Summary Worksheet

U.S. Department of Labor
Employment and Training Administration

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

Work Opportunity Tax Credit
Audit Summary Worksheet
1. NAME OF JOB APPLICANT / NEW HIRE
For State Workforce Agency
(SWA) Internal Use Only

(Last, First, Middle Initial)

2. APPLICANT’S SOCIAL SECURITY
NUMBER

3. EMPLOYER’S NAME, TELEPHONE NUMBER, AND ADDRESS:

THE SECTION BELOW IS TO BE COMPLETED BY THE SWA / CERTIFYING AGENCY ONLY
4. CERTIFYING AGENCY: (Check “√” one)
Conditional Certification was issued by:
(PA)

5. DATE CERTIFIED:(mm/dd/yyyy)
Participating Agency
State Workforce Agency

6. SOURCES USED TO DOCUMENT APPLICANT’S/NEW HIRE’S TARGETED GROUP ELIGIBILITY: (List all documentation provided)

7. AUDIT SAMPLE RESULTS: (Complete ONLY if selected as part of RANDOM SAMPLE in a quarterly audit)
a.  I have reviewed/contacted the source(s) indicated in box 6 and have confirmed that the certified individual is
ELIGIBLE.
b.  I have reviewed/contacted the source(s) indicated in box 6 and have confirmed that the certified individual is
INELIGIBLE for the following reason(s):
c.  I have not been able to establish that the certified individual is INELIGIBLE because:
Note: 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.

8. NAME AND TITLE OF SWA REVIEWER:
(Type or Print):

9. CERTIFYING OFFICER’S SIGNATURE:

10. DATE:

Persons are not required to respond to this collection of information unless it displays a valid OMB Control Number. Respondents’
obligation to reply to these requirements is mandatory by P.L. 104-188. Public reporting burden for this collection of information is estimated
to average 1 hour 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 US. 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).
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 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 9065 (Rev. May 2023)

AUDIT SUMMARY WORKSHEET, ETA FORM 9065, INSTRUCTIONS.
Background:
The Omnibus Budget Reconciliation Act of 1990, (P.L. 101-508, §11405(c)), extended indefinitely the $5 million set-aside (cited
below) for testing whether individuals certified as members of WOTC targeted groups are eligible for certification (including the use
of statistical sampling techniques). Section 261(f)(2) of the Economic Recovery Tax Act of 1981 (P.L. 97-34), states that:
“(A) $5,000,000, shall be used to test whether individuals certified as members of targeted groups under section 51
of such Code [Internal Revenue] are eligible for such certification (including the use of statistical sampling techniques),
and (B) the remainder shall be distributed under performance standards prescribed by the Secretary of Labor.”
Verification activities require testing the validity of all Certifications issued by the SWAs, including Conditional Certifications issued by
Participating Agencies. A General Accounting Office (GAO) report recommended that verification activities be completed by an employee "other
than the person who originally processed" the Individual Characteristics Form [ETA Form 9061] or Conditional Certification [ETA Form 9062].

DEFINITIONS:
1. Quality Review - ETA recommends SWAs conduct a review of each certification request (WOTC Processing Forms, supporting
documentation, and Employer Certifications issued) as a quality control method. During the initial review, the SWA should determine if the
certification request (IRS Form 8850) was timely filed and complete. Quality reviews are part of the SWAs’ administrative responsibilities to
ensure the required information for employers’ certification requests is complete and accurately recorded.
2. Audit - To reduce the chances of erroneously certifying ineligible persons for WOTC, SWAs must conduct quarterly audits.
A quarterly audit is a verification activity to examine the quality of the SWA’s certification process. If the SWA issued an
incorrect Certification, the SWA must revoke the Certification. For those applications found to be ineligible, the SWA must issue
a notice of invalidation (NOI) or notice of revocation (NOR) based on the review of Certifications / supporting documentation.

INSTRUCTIONS FOR COMPLETING THE AUDIT SUMMARY WORKSHEET, ETA FORM 9065 (OPTIONAL)
This worksheet is an optional Form for SWAs’ internal use in recording the results of verification activities conducted
by the SWA. States are not required to submit this Form to ETA. The Form’s design and format are optional; states
can change the design and format to meet their reporting needs.
Box 1.

Name of Individual. Enter the full name (last, first and middle initial) of the individual certified as a targeted group member.

Box 2.

Social Security Number. Enter the individual’s (applicant’s) 9-digit social security number.

Box 3.

Employer Name, Telephone No., & Address. Enter the employer's name, address including zip code, and telephone number.

Box 4.

Certifying Agency. Enter name of SWA issuing the Employer Certification. Indicate with a checkmark “” whether the CC was
issued by a Participating Agency (PA) or a SWA.

Box 5.

Date Certified. Enter month, day and year when the Certification was issued by the SWA.

Box 6.

Documentary Sources. List and/or describe the documentary evidence or sources of collateral contacts that were attached to the
certification request (IRS Form 8850) and/or Individual Characteristics Form (ETA Form 9061).

Box7.

Audit Sample Results. Upon review of documentation during the audit, indicate with a checkmark “” if the individual is "eligible,”
“ineligible,” or “eligibility cannot be determined.” Follow the instructions below based on the audit outcomes:
a. If review of documentation reveals that the certified individual is eligible, enter a checkmark “” by “eligible.”
b. If review of documentation reveals that the certified individual is ineligible, explain why. If review reveals that the SWA has not
been able to establish eligibility, provide the reason. For Conditional Certifications (CCs) , prepare and send the following notices:
U

U

Notification of Invalidation (NOI) - The NOI notifies the Participating Agency (PA), job applicant, and employer seeking
Certification that the Conditional Certification (CC) is INVALID due to missing or incorrect information/items. Copies of the NOI
should be sent to the applicant, PA (authorized official), and employer/authorized representative (where appropriate).
Notice of Revocation (NOR) - The NOR should communicate to the employer the reason why the SWA was not able to
determine that the employee is a member of a targeted group, and the effective date of the revocation. The NOR should also
inform affected employers that wages paid to the “non-eligible” employee cannot continue to be treated as “qualified wages” for
WOTC purposes. SWAs should send the NOR to the employer/authorized representative (where appropriate), and the IRS.
SWAs can transmit the NOR to IRS at the following IRS fax number:

Box 8.

Internal Revenue Service
Small Business/Self-Employed Campus Compliance Services
Fax: 1-855-242-6540
Name and Title of Reviewer. Enter full name and title of authorized SWA staff conducting audit review.

Box 9.

Signature. Enter signature of authorized reviewer conducting audit.

Box 10. Date. Enter date (mm/dd/yyyy) when audit was conducted by SWA.

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ETA Form 9065 (Rev. May 2023)