U.S. Department Of Labor Employment and Training Administration
OMB Control No. 1205-0371 Expiration Date: March 31, 2023
Individual Characteristics Form (ICF) Work Opportunity Tax Credit
1.Control No. (For Agency use only)
2.Date Received (For Agency Use only)
APPLICANT INFORMATION (See instructions on reverse)
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 ___
If YES , enter your date of birth _____________________ 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? 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 ___
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 ___ 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 _____________________. 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? Yes ___ No___ 16. Are you a member of a family that received TANF assistance for at least the last 18 months 1
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