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Qualified Long-term Unemployment Recipient (LTUR)
Work Opportunity Tax Credit
OMB: 1205-0371
IC ID: 221431
OMB.report
DOL/ETA
OMB 1205-0371
ICR 202308-1205-002
IC 221431
( )
Documents and Forms
Document Name
Document Type
Form ETA-9175
Qualified Long-term Unemployment Recipient (LTUR)
Form
Form ETA-9175
Qualified Long-term Unemployment Recipient (LTUR)
Form
ETA-9175 LONG-TERM UNEMPLOYMENT RECIPIENT SELF-ATTESTATION FORM W
ETA_Form_9175_LTUR_Self-Attestation_Form.pdf
Form
ETA-9175 LONG-TERM UNEMPLOYMENT RECIPIENT SELF-ATTESTATION FORM W
ETA_Form_9175_LTUR_Self-Attestation_Form.pdf
Form
ETA Form 9175 - LTUR Self Attestation Form redline Edits.docx
ETA-9175-Tracked Changes
IC Document
ETA Form 9175 - LTUR Self Attestation Form redline Edits.docx
ETA-9175-Tracked Changes
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Qualified Long-term Unemployment Recipient (LTUR)
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
ETA-9175
LONG-TERM UNEMPLOYMENT RECIPIENT SELF-ATTESTATION FORM Work Opportunity Tax Credit (WOTC) Program
ETA_Form_9175_LTUR_Self-Attestation_Form.pdf
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Workforce Management
Subfunction:
Training and Employment
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
233,160
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits, Farms, Not-for-profit institutions
Percentage of Respondents Reporting Electronically:
50 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
233,160
0
0
0
0
233,160
Annual IC Time Burden (Hours)
39,637
0
0
0
0
39,637
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
ETA-9175-Tracked Changes
ETA Form 9175 - LTUR Self Attestation Form redline Edits.docx
02/14/2023
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.