Overview
Updated 03/17/2023
Federal PDF Version: Attachment 5A-Individual Characteristics Form (ICF) Work Opportunity Tax Credit (dol.gov)
Entry requirements are featured below. Field data requirements are the following:
Page 1
The first page of the 9061 Work Opportunity Tax Credit form features Agency, Employer, and Employee fields.
Note: Nothing gets pre-populated in this section as per the instruction released by USCIS. If anything on this section is pre-populated, then this form will be out of compliance.
| Field Key # | Field Description | Pre-Populates From | Required | Validation Notes |
|---|---|---|---|---|
| 1 | Control No. | NA | For Agency Use Only | |
| 2 | Date Received | NA | For Agency Use Only | |
| 3 | Employer Name | Company Record | Yes | |
| 4 | Employer Address and Telephone | Company Record | Yes | |
| 5 | Employer Federal ID Number (EIN) | Company Record | Yes | |
| 6 | Applicant Name | Applicant Record | Yes | |
| 7 | Social Security Number | Applicant Record | Yes | |
| 8 |
Have you worked for this employer before? Yes ____ No ____ |
N/A | Yes | |
| 9 | Employment Start Date | N/A | No | |
| 10 | Starting Wage | N/A | No | |
| 11 | Position | N/A | ||
| 12 |
Are you at least age 16, but under age 40? Yes ___ No ___ |
N/A | Yes |
Check marks for "Yes" or "No"
If "Yes", enter date of birth in ##/##/#### format. |
| 13 | Are you a Veteran of the U.S. Armed Forces? Yes ___ No ___ If NO, go to Box 14. If YES, are you a member of a family that received Supplemental Nutrition Assistance Program (SNAP) benefits (Food Stamps) for at least 3 months during the 15 months before you were hired? Yes ___ No ___ If YES, enter name of primary recipient _______________________ and city and state where benefits were received _________________. OR, are you a veteran entitled to compensation for a service-connected disability? Yes ___ No ___ If YES, were you discharged or released from active duty within a year before you were hired? Yes ___ No ___ OR, were you unemployed for a combined period of at least 6 months (whether or not consecutive) during the year before you were hired? Yes ___ No ___ |
N/A | Yes |
Check marks for "Yes" or "No" questions.
If "Yes", free text in corresponding blank spaces. |
| 14 | Are you a member of a family that received Supplemental Nutrition Assistance Program (SNAP) (formerly Food Stamps) benefits for the 6 months before you were hired? Yes ___ No___ OR, received SNAP benefits for at least a 3-month period within the last 5 months But you are no longer receiving them? Yes ___ No___ If YES to either question, enter name of primary recipient _____________________ and city And state where benefits were received _____________________. |
N/A | Yes |
Check marks for "Yes" or "No" questions.
If "Yes", free text in corresponding blank spaces. |
| 15 | Were you referred to an employer by a Vocational Rehabilitation Agency approved by a State? Yes ___ No___ OR, by an Employment Network under the Ticket to Work Program? Yes ___ No___ OR, by the Department of Veterans Affairs? |
N/A | Yes | |
| 16 | Are you a member of a family that received TANF assistance for at least the last 18 months 2 before you were hired? Yes___ No___ OR, are you a member of a family that received TANF benefits for any 18 months beginning after August 5, 1997, and the earliest 18-month period beginning after August 5, 1997, ended within 2 years before you were hired? Yes___ No___ OR, did your family stop being eligible for TANF assistance within 2 years before you were hired because a Federal or state law limited the maximum time those payments could be made? Yes___No___ If NO, are you a member of a family that received TANF assistance for any 9 months during the 18-month period before you were hired? Yes___No___ If YES, to any question, enter name of primary recipient ________________________ and the city and state where benefits were received _________________________. |
N/A | Yes |
Check marks for "Yes" or "No" questions.
If "Yes", free text in corresponding blank spaces. |
Page 2
| Field Key # | Field Description | Pre-Populates From | Required | Validation Notes |
|---|---|---|---|---|
| 17 | Were you convicted of a felony or released from prison after a felony conviction during the year before you were hired? Yes___No___ If YES, enter date of conviction ________________ and date of release _________________. Was this a Federal ____ or a State conviction_____? (Check one) |
N/A | No | If "Yes", free text in corresponding blank spaces. |
| 18 | Do you live in an Empowerment Zone or Rural Renewal County (RRC)? Yes__ No __ | N/A | No | Check marks for "Yes" or "No" questions. |
| 19 | Do you live in an Empowerment Zone and are at least age 16, but not yet 18, on your hiring date? Yes __ No __ | N/A | No | Check marks for "Yes" or "No" questions. |
| 20 | Did you receive Supplemental Security Income (SSI) benefits for any month ending within 60 days before you were hired? Yes__ No__ | N/A | No | Check marks for "Yes" or "No" questions. |
| 21 | Are you a veteran unemployed for a combined period of at least 6 months (whether or not consecutive) during the year before you were hired? Yes__ No__ | N/A | No | Check marks for "Yes" or "No" questions. |
| 22 | Are you a veteran unemployed for a combined period of at least 4 weeks but less than 6 months (whether or not consecutive) during the year before you were hired? Yes__ No__ | N/A | No | Check marks for "Yes" or "No" questions. |
| 23 | Are you an individual who is or was in a period of unemployment that is at least 27 consecutive weeks the day before you began to work for the employer, or if earlier, the day you completed IRS Form 8850, the Prescreening Form? Yes__ No__ If YES, did you receive unemployment compensation/benefits under State or Federal law during a period of unemployment? Yes__ No__ |
N/A | No | Check marks for "Yes" or "No" questions. |
| 24 | Sources used to document eligibility: (Employers/Consultants: List all documentation provided or forthcoming. For SWA Staff: List all documentation used in determining target group eligibility and enter your initials and date when the determination was made. | N/A | No | Free-text |
| 25(a) | Signature: (See instructions in Box 25.(b) for who signs this signature block) | N/A | Yes | Check mark acting as signature. |
| 25(b) | Indicate with a mark who signed this form: Employer, Consultant, SWA, Participating Agency, Applicant, or Parent/Guardian (if applicant is a minor) |
N/A | Yes | Single check mark |
| 26 | Date: | Current Date | N/A |
Troubleshooting
If the form will not close, there may be an error in a field that can't be seen without scrolling. Check all fields for error messages. Some fields that require punctuation structure - e.g. Date of Birth 3/29/71 - may have a format error.
