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2016 03 8850.pdf

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Jackie Mae Rangel
630-18-9566
2297 wickersham lane Apt 205
Austin TX 78741
09/18/1990
Travis
737-267-2265
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Jackie Mae Rangel 04/23/2021 05:14:05 PM GMT
800-859-7479
10499 W Bradford RD. Suite 102
Littleton CO 80127
KeyStaff, Inc.
2417 Ashdale Dr Suite A
Austin TX 78757
512-666-3725
09/21/2018
04/23/2021
45-0524285
Dir, WOTC Operations
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)
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 ___
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? 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 ___
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
2417 Ashdale Dr Suite A
Austin TX 78757
512-666-3725
45-0524285
KeyStaff, Inc.
Rangel, Jackie M
630-18-9566
09/18/1990
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Jackie Rangel
Austin, TX
✔
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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 _________________________.
17. Were you convicted of a felony or released from prison after a felony conviction during
t
he year before you were hir
ed? Y
es___No___
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)? Yes__ No __
19. Do you live in an Empowerment Zone and are at least age 16, but not yet 18, on Yes __ No __
your hiring dat
e?
20. Did you receive Supplemental Security Income (SSI) benefits for any month ending within
60 days before you were hired? Yes__ No__
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__
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__
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? Yes__ No_
_
I
f YES, what state did you receive unemployment compensation in? ______________________
___
(Enter state where UI compensation was received)
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, SW
A,
P
articipating Agency, Applicant,
or
Parent/Guardian (if applicant is a
minor)
26. Date:
ETA Form 9061 (Rev. November 2016)
2
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Completed 25 April 2021

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