*

U.S. Department Labor

Employment and Training Administration

OMB No. 1205-0371

Expiration Date: March 31, 2023

Individual Characteristics Form (ICF)

Work Opportunity Tax Credit

1. Control No. (For Agency use only)

APPLICANT INFORMATION

(See instructions on reverse)

2. Date Received (For Agency Use only)

EMPLOYER INFORMATION

3. Employer Name 4. Employer Address and Telephone 5. Employer Federal ID Number (EIN) APPLICANT INFORMATION

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? Yes No Enter your date of birth

13. Are you a Veteran of the U.S. Armed Forces?

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?

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? If YES, were you discharged or released from active duty within a year before you were hired? OR, were you unemployed for a combined period of at least 6 months (whether or not consecutive) during the year before you were hired? 14.

15.

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Were you referred to an employer by a Vocational Rehabilitation Agency approved by a State?

OR, by an Employment Network under the Ticket to Work Program? OR, by the Department of Veterans Affairs?

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? OR, received SNAP benefits for at least a 3-month period within the last 5 months But you are no longer receiving them?

If YES to either question, enter name of primary recipient and city And state where benefits were received . Yes No

Yes No

Yes No

Yes No

If YES, XX/XX/1951

X

07/03/2020

X

Kutsi Cheryl J

08/26/2020

6600 Corporate Center Pkwy

Jacksonville

Acosta Inc. XXXXXXXX52

904-***-****

FL 33216

Metchandiser

XXX-XX-XX00

13

2

before you were hired?

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?

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? 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?

If YES, to any question, enter name of primary recipient and the city and state where benefits were received . 17. Were you convicted of a felony or released from prison after a felony conviction during the year before you were hired?

If YES, enter date of conviction and date of release . Was this a Federal or a State conviction ? (Check one) 18. Do you live in an Empowerment Zone or Rural Renewal County (RRC)? 19. Do you live in an Empowerment Zone and are at least age 16, but not yet 18, on your hiring date?

20. Did you receive Supplemental Security Income (SSI) benefits for any month ending within 60 days before you were hired?

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? 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? 23. Are you an individual who is or was in a period of unemployment that is at least 27 consecutive weeks and for all or part of that period you received unemployment compensation?

If YES, what state did you receive unemployment compensation in? 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.

I certify that this information is true and correct to the best of my knowledge. I understand that the information above may be subject to verification.

25(a). Signature: (See instructions in Box 25.(b) for who signs this signature block)

25.(b) Indicate with a mark who

signed this form:

Employer, Consultant, SWA,

Participating Agency, Applicant, or

Parent/Guardian (if applicant is a

minor)

26. Date:

ETA Form 9061 (Rev. November 2016)

16.months Are you a member of a family that received TANF assistance for at least the last 18 Yes No Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

(Enter state where UI compensation was received)

Cheryl J Kutsi (8/20/20 20:36:58 -5) X

08/20/2020

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