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Get And Sign Attachment 5A Individual Characteristics Form ICF Work Opportunity Tax Credit ETA Form 9061 Rev November

Instructions on reverse 3. Employer Name EMPLOYER INFORMATION 4. Employer Address and Telephone 5. Employer Federal ID Number EIN 6. Applicant Name Last First MI 7. Social Security Number 8. Have you worked for this employer before Yes No If YES enter last date of employment APPLICANT CHARACTERISTICS FOR WOTC TARGET GROUP CERTIFICATION 9. Employment Start Date 10. Starting Wage 11. Position 12. Are you at least age 16 but under age 40 If YES enter your date of birth Yes No 13. Are you a Veteran...

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