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eDocument - 9061 WOTC Form

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Federal PDF Version: https://www.uscis.gov/sites/default/files/files/form/i-9.pdf 

Entry requirements are featured below. Field data requirements are 

 

Page 1

The first page of the 9061 Work Opportunity Tax Credit form features Agency, Employer, and Employee fields. 

 

wotc_eta_form_9061-1.png

 

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 ____
If YES, enter last date of employment: ____________

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 ___
If YES, enter your date of birth _____________________

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 Included in next section  N/A    

 

 

 

Page 2

 

wotc_eta_form_9061-2.png

 

 

Field Key # Field Description Pre-Populates From Required Validation Notes
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.

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

 

 

 

Page 3

wotc_eta_form_9061-3.png

 

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. 

 

 


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